NORTH EAST FLORIDA EDUCATIONAL CONSORTIUM /
GILCHRIST COUNTY SCHOOL BOARD
EMPLOYEE BENEFITS PROGRAM
(Dental, Vision, Short-Term Disability, Life Insurance & AD&D)
NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN OBTAIN ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
The North East Florida Educational Consortium/Gilchrist County School Board’s Employee Benefits Program (the “Plan”) is required by law to take reasonable steps to ensure the privacy of your personally identifiable health information and to inform you about:
• The Plan’s uses and disclosures of Protected Health Information (“PHI”);
• Your privacy rights with respect to your PHI;
• The Plan’s duties with respect to your PHI;
• Your right to file a complaint with the Plan and to the Secretary of the U.S. Department of Health and Human Services; and
• The person or office to contact for further information about the Plan’s privacy practices.
The term “Protected Health Information” includes all individually identifiable health information about your past, present or future physical or mental condition that is transmitted or maintained by the Plan, regardless of form (oral, written, or electronic).
Section 1. Notice of PHI Uses and Disclosures:
Upon your request, the Plan is required to give you access to certain PHI in order to inspect and copy such information. Use and disclosure of your PHI may be required by the Secretary of the U.S. Department of Health and Human Services to investigate or determine the Plan’s compliance with federal privacy regulations.
Uses and Disclosures to Carry Out Treatment, Payment and Health Care Operations:
The Plan and its business associates will use your PHI without your consent, authorization or opportunity to agree or object to carry out treatment, payment and health care operations. The Plan also will disclose PHI to the Plan Sponsor, Gilchrist County School Board, for purposes of Plan administrative functions related to treatment, payment and health care operations. The Plan Sponsor has amended its plan documents to protect your PHI as required by federal law.
In order for the Plan to pay for your covered medical expenses, the Plan and those administering the Plan must create or receive certain medical information about you. This information may be obtained through the following activities:
• Treatment activities by your health care provider, such as providing information about other treatments you have received.
• Payment activities such as billing and collection activities, eligibility determinations, adjudication of claims, precertification and utilization review, and coordination of benefits.
• Health Care Operations activities such as quality assessment, case management, subrogation or business management and general administrative activities.
Uses or Disclosures That Require Your Written Authorization:
Your written authorization generally will be obtained before the Plan will use or disclose psychotherapy notes about you from your psychotherapist. Psychotherapy notes are separately filed notes about your conversations with your mental health professional during a counseling session. They do not include summary information about your mental health treatment. The Plan may use and disclose such notes when needed by the Plan to defend against any litigation you may file.
Uses and Disclosures That Require That You Be Given an Opportunity to Agree or Disagree Prior to the Use or Release:
Disclosure of your PHI to family members, other relatives and your close personal friends is allowed if:
• The information is directly relevant to the family or friend’s involvement with your care or payment for that care; and
• You have either agreed to the disclosure or have been given an opportunity to object and have not objected.
Uses and Disclosures for Which Consent, Authorization or Opportunity to Object are Not Required:
Use and disclosure of your PHI is allowed without your consent, authorization or opportunity to object under the following circumstances:
• When required by law.
• When permitted for purposes of public health activities.
• When authorized by law to report information about abuse, neglect or domestic violence to public authorities if there exists a reasonable belief that you may be a victim of abuse, neglect or domestic violence. In such case, the Plan will promptly inform you that such a disclosure has been or will be made unless that notice would cause a risk of serious harm.
• The Plan may disclose your PHI to a public health oversight agency for oversight activities authorized by law.
• The Plan may disclose your PHI when required for judicial or administrative proceedings.
• When required for law enforcement purposes (for example, to report certain types of wounds).
• For law enforcement purposes, including for the purpose of identifying or locating a suspect, fugitive, material witness or missing person.
• When required to be given to a coroner or medical examiner for purposes of identifying a deceased person, determining a cause of death or other duties as authorized by law.
• The Plan may use or disclose PHI for research, subject to conditions.
• To avert a serious threat to health or safety if the Plan believes it is necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person.
• When authorized by and to the extent necessary to comply with workers’ compensation or other similar programs established by law.
• If you are a member of the armed forces, we may release PHI about you as required by military command authorities.
• We may release PHI about you to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.
The Plan will obtain your written authorization before using or disclosing PHI about you for purposes other than those provided above or as otherwise permitted or required by law. You may revoke authorization in writing at any time. Upon receipt of the written revocation, we will stop using or disclosing PHI about you, except to the extent that we have already taken action in reliance on the authorization.
Section 2. Rights of Individuals:
You may request the Plan to restrict uses and disclosures of your PHI to carry out treatment, payment or health care operations, or to restrict uses and disclosures to family members, relatives, friends or other persons identified by you who are involved in your care or payment for your care. However the Plan is not required to agree to your request.
The Plan will accommodate reasonable requests to receive communications of PHI by alternative means or at alternative locations. You or your personal representative will be required to complete a form to request restrictions on uses and disclosures of your PHI.
Such requests should be made to the Plan’s Privacy Officer as set forth in Section 5 at the end of this Notice.
You have the following rights regarding your PHI:
The Right to Request Restrictions on PHI Uses and Disclosures
• To request restrictions on certain uses and disclosures of your PHI. The Plan does not have to agree with a requested restriction, but if the Plan does agree, then the Plan will abide by that restriction.
The Right to Access, Inspect and Copy PHI
• To access, inspect and copy your own health information, but exceptions apply to certain types of information. If you request to see or copy your own health information from the Plan’s Privacy Officer and one of these exceptions apply, you will be given more information at that time, including the circumstances under which you may challenge the exception.
The Right to Amend PHI
To amend your own health information when that information is incorrect, with certain exceptions that will be communicated to you if you seek to amend your own health information.
The Right to Receive an Accounting of Disclosures of PHI
• To obtain an accounting of any disclosure of your confidential health information, other than disclosures for purposes of treatment, payment or health care operations, or disclosures made in accordance with your written authorization.
The Right to Receive a Paper Copy of this Notice
• To obtain a paper copy of this Notice upon request.
In each case, you must make your request to the Privacy Officer in writing as set forth in Section 5 of this Notice. Depending upon the nature of the request, you will be given more information at that time, including any exceptions to the rules that may apply to your case.
Section 3. The Plan’s Duties:
The Plan is required by law to maintain the privacy of PHI and to provide individuals (participants and beneficiaries) with notice of its legal duties and privacy practices. This Notice is effective on the date set forth in Section 6 of this Notice. The Plan is required to comply with the terms of this Notice, however, the Plan reserves the right to change its privacy practices and to apply the changes to any PHI received or maintained by the Plan prior to that date. If a privacy practice is changed, all Plan participants will receive a revised Notice within 60 days of a material revision to the Notice.
Section 4. Your Right to File a Complaint:
If you believe that your privacy rights have been violated, you may complain to the Plan in care of the Plan’s Privacy Officer at the below listed address. You may also file a complaint with the U.S. Secretary of the Department of Health and Human Services. You will not be penalized for filing a complaint.
Section 5. Whom to Contact at the Plan:
If you have any questions regarding this Notice or the subjects addressed in this Notice, you may contact the Plan’s Privacy Officer as follows:
Privacy Officer
Gilchrist County School Board
310 NW 11th Avenue
Trenton, FL 32693
(352) 463-3200
Section 6. Effective Date of this Notice:
April 14, 2003