Fillable Your Information. Your Rights. Our Responsibilities. (Cook Children's Health Plan)

Fill Online, Printable, Fillable, Blank Your Information. Your Rights. Our Responsibilities. (Cook Children's Health Plan) Form

Use Fill to complete blank online COOK CHILDREN'S HEALTH PLAN pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Your Information. Your Rights. Our Responsibilities. (Cook Children's Health Plan)

On average this form takes 2 minutes to complete

The Your Information. Your Rights. Our Responsibilities. (Cook Children's Health Plan) form is 5 pages long and contains:

  • 0 signatures
  • 0 check-boxes
  • 6 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your Cook Children's Health Plan forms online.

BROWSE COOK CHILDREN'S HEALTH PLAN FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
We may use and share your information as we:
• Help manage the health care treatment you receive
• Run our organization
• Pay for your health services
• Administer your health plan
• Help with public health and safety issues
• Do research
• Comply with the law
• Respond to organ and tissue donation requests and
work with a medical examiner or funeral director
• Address workers’ compensation, law enforcement,
and other government requests
• Respond to lawsuits and legal actions
➤ See pages 3 and 4
for more information
on these uses and
disclosures
You have the right to:
• Get a copy of your health and claims records
• Correct your health and claims records
• Request confidential communication
• Ask us to limit the information we share
• Get a list of those with whom we’ve shared
your information
• Get a copy of this privacy notice
• Choose someone to act for you
• File a complaint if you believe your privacy
rights have been violated
➤ See page 2 for
more information on
these rights and how
to exercise them
Our
Uses and
Disclosures
Your
Rights
➤ See page 3 for
more information on
these choices and
how to exercise them
You have some choices in the way that we
use and share information as we:
• Answer coverage questions from your family and friends
• Provide disaster relief
• Market our services and sell your information
This notice describes how medical information about
you may be used and disclosed and how you can get
access to this information. Please review it carefully.
Your Information.
Your Rights.
Our Responsibilities.
Your
Choices
Notice of Privacy Practices • Page 1
Cook Children's Health Plan
P.O. Box 2488, Fort Worth, Texas
76113-2488
Privacy Official: Kathleen Roman
Phone: 682-885-2866
Email: kathy.roman@cookchildrens.org
website: www.cookchp.org
Notice of Privacy Practices • Page 2
When it comes to your health information, you have certain rights.
This section explains your rights and some of our responsibilities to help you.
Your
Rights
Get a copy of your
health and claims
records
• You can ask to see or get a copy of your health and claims records and other health
information we have about you. Ask us how to do this.
• We will provide a copy or a summary of your health and claims records, usually within
30 days of your request. We may charge a reasonable, cost-based fee.
Ask us to correct
health and claims
records
• You can ask us to correct your health and claims records if you think they are
incorrect or incomplete. Ask us how to do this.
• We may say “no” to your request, but we’ll tell you why in writing within 60 days.
Request confidential
communications
• You can ask us to contact you in a specific way (for example, home or office phone)
or to send mail to a different address.
• We will consider all reasonable requests, and must say “yes” if you tell us you would
be in danger if we do not.
Ask us to limit what
we use or share
• You can ask us not to use or share certain health information for treatment,
payment, or our operations.
• We are not required to agree to your request, and we may say “no” if it would affect
your care.
Get a list of those
with whom we’ve
shared information
• You can ask for a list (accounting) of the times we’ve shared your health information
for six years prior to the date you ask, who we shared it with, and why.
• We will include all the disclosures except for those about treatment, payment, and
health care operations, and certain other disclosures (such as any you asked us to
make). We’ll provide one accounting a year for free but will charge a reasonable,
cost-based fee if you ask for another one within 12 months.
Get a copy of this
privacy notice
• You can ask for a paper copy of this notice at any time, even if you have agreed to
receive the notice electronically. We will provide you with a paper copy promptly.
Choose someone
to act for you
• If you have given someone medical power of attorney or if someone is your legal
guardian, that person can exercise your rights and make choices about your health
information.
• We will make sure the person has this authority and can act for you before we take
any action.
File a complaint if
you feel your rights
are violated
• You can complain if you feel we have violated your rights by contacting us using the
information on page 1.
• You can file a complaint with the U.S. Department of Health and Human Services
Ofce for Civil Rights by sending a letter to 200 Independence Avenue, S.W.,
Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/
privacy/hipaa/complaints/.
• We will not retaliate against you for filing a complaint.
Notice of Privacy Practices • Page 3
In these cases, you have
both the right and choice
to tell us to:
• Share information with your family, close friends, or others involved in payment
for your care
• Share information in a disaster relief situation
If you are not able to tell us your preference, for example if you are unconscious,
we may go ahead and share your information if we believe it is in your best interest.
We may also share your information when needed to lessen a serious and imminent
threat to health or safety.
In these cases we never
share your information
unless you give us
written permission:
• Marketing purposes
• Sale of your information
For certain health information, you can tell us your choices about what
we share. If you have a clear preference for how we share your information in the
situations described below, talk to us. Tell us what you want us to do, and we will follow
your instructions.
Your
Choices
Help manage
the health care
treatment you
receive
• We can use your health information
and share it with professionals who are
treating you.
Example: A doctor sends us information
about your diagnosis and treatment plan
so we can arrange additional services.
Run our
organization
• We can use and disclose your information
to run our organization and contact you
when necessary.
• We are not allowed to use genetic
information to decide whether we will
give you coverage and the price of that
coverage. This does not apply to long term
care plans.
Example: We use health information
about you to develop better services
for you.
Pay for your
health services
•
We can use and disclose your health
information as we pay for your health
services.
Example: We share information about
you with your dental plan to coordinate
payment for your dental work.
Administer
your plan
• We may disclose your health information
to your health plan sponsor for plan
administration.
Example: Your company contracts with us
to provide a health plan, and we provide
your company with certain statistics to
explain the premiums we charge.
How do we typically use or share your health information?
We typically use or share your health information in the following ways.
Our
Uses and
Disclosures
continued on next page
Notice of Privacy Practices • Page 4
Help with public health
and safety issues
• We can share health information about you for certain situations such as:
• Preventing disease
• Helping with product recalls
• Reporting adverse reactions to medications
• Reporting suspected abuse, neglect, or domestic violence
• Preventing or reducing a serious threat to anyone’s health or safety
Do research
• We can use or share your information for health research.
Comply with the law
• We will share information about you if state or federal laws require it,
including with the Department of Health and Human Services if it wants to
see that we’re complying with federal privacy law.
Respond to organ and tissue
donation requests and work
with a medical examiner or
funeral director
• We can share health information about you with organ procurement
organizations.
• We can share health information with a coroner, medical examiner, or funeral
director when an individual dies.
Address workers’
compensation, law
enforcement, and other
government requests
• We can use or share health information about you:
• For workers’ compensation claims
• For law enforcement purposes or with a law enforcement official
• With health oversight agencies for activities authorized by law
• For special government functions such as military, national security, and
presidential protective services
Respond to lawsuits and
legal actions
• We can share health information about you in response to a court or
administrative order, or in response to a subpoena.
How else can we use or share your health information? We are allowed or required to share your
information in other ways – usually in ways that contribute to the public good, such as public health and research.
We have to meet many conditions in the law before we can share your information for these purposes. For more
information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.
Cook Children's Health Plan never markets or sells personal information.
Notice of Privacy Practices • Page 5
Our Responsibilities
• We are required by law to maintain the privacy and security of your protected health information.
• We will let you know promptly if a breach occurs that may have compromised the privacy or security
of your information.
• We must follow the duties and privacy practices described in this notice and give you a copy of it.
• We will not use or share your information other than as described here unless you tell us we can in
writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you
change your mind.
For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.
Changes to the Terms of this Notice
We can change the terms of this notice, and the changes will apply to all information we have about you.
The new notice will be available upon request, on our web site, and we will mail a copy to you.
This Notice of Privacy Practices applies to the following organizations.
Effective: 09/07/2013
Cook Children's Health Plan
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Your Information. Your Rights. Our Responsibilities. (Cook Children's Health Plan)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 7 May 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document