NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES:

  • HOW PROTECTED HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

 

  • YOUR RIGHTS WITH RESPECT TO YOUR HEALTH INFORMATION

  • HOW TO FILE A COMPLAINT CONCERNING A VIOLATION OF THE PRIVACY OR SECURITY OF YOUR HEALTH INFORMATION, OR OF YOUR RIGHTS CONCERNING YOUR INFORMATION

 

YOU HAVE A RIGHT TO A COPY OF THIS NOTICE (IN PAPER OR ELECTRONIC FORM) AND TO DISCUSS IT WITH Avēsis ACE AT 855-214-6777 AND PRIVACYOFFICE@AVESIS.COM IF YOU HAVE ANY QUESTIONS.

 

The Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) allows covered entities under common ownership or control to join together to form a “single affiliated covered entity” for purposes of compliance with HIPAA. The following organizations form the Avēsis Affiliated Covered Entity (“Avēsis ACE”) and are covered by this notice:

  • Premier Access Insurance Company (“PAIC”)
  • Avēsis Insurance Incorporated (“Avēsis Insurance”)
  • Access Dental Plan of Nevada, Inc. (“ADP Nevada”)
  • Access Dental Plan (“ADP California”)
  • Access Dental Plan of Utah, Inc. (“ADP Utah”)

 

Avēsis ACE may be referred to in this notice as “we,” “our,” or “us.” Certain entities under the ACE operate programs protected under the federal law regarding the confidentiality of substance use disorder referred to as Part 2.

 

All correspondence relating to the contents of this notice should be directed to the following contact: Avēsis, LLC, Privacy Office, 1295 W. Washington St Suite 212 Tempe, AZ 85288.

 

 

This Notice tells you about the ways Avēsis ACE may collect, store, use and disclose your protected health information and your rights concerning your protected health information. Protected Health Information (PHI) is information about you that can reasonably be used to identify you and that relates to your past, present or future physical or mental health or condition, the provision of health care to you or the payment for that care.

 

Federal and state laws require us to provide you with this Notice about your rights and our legal duties and privacy practices with respect to your protected health information. We must follow the terms of this Notice while it is still in effect. Some of the uses and disclosures described in this Notice may be limited in certain cases by applicable state laws that are more stringent than the federal standards.

Uses and Disclosures of Your Protected Health Information

We may use and disclose your protected health information for different purposes. The examples below are illustrations of the different types of uses and disclosures that we may make without obtaining your authorization, subject to the requirements in 42 C.F.R. Part 2, as applicable, and other more strict applicable laws.

 

  • We may use and disclose your protected health information to pay for your covered health expenses. For example, we may use your protected health information to process claims or be reimbursed by another insurer that may be responsible for payment.
  • We may use and disclose your protected health information to assist your health care providers (i.e., dentists, ophthalmologist) with your services/benefits or to
  • coordinate treatment.
  • Health Care Operations. We may use and disclose your protected health information to perform our plan activities, such as quality assessment activities, or administrative activities, including data management or customer service. In some cases, we may use or disclose the information for underwriting and premium rating purposes. We are prohibited from using or disclosing protected health information, that is genetic information of an individual for underwriting purposes.
  • Disclosures to Employers or Health Plan Sponsor. We may use or disclose PHI to the plan sponsor of your group health plan to permit the plan sponsor to perform plan administration functions including summary health information about members, i.e., benefit services, to obtain bids and enrollment/disenrollment or pursuant to your authorization. Otherwise, we will not disclose your personal health information to your employer or group health plan sponsor unless they have elected to sign a HIPAA Plan Sponsor (Employer) Certification Form (AV014373).
  • Business Associates. We may disclose your health information to our business associates. We have contracted with entities (defined as “business associates” under HIPAA) to help us administer your benefits. We will enter into contracts with these entities requiring them to only use and disclose your health information as we are permitted to do so under HIPAA.

 

 

Other Permitted or Required Disclosures

  • To you. We must disclose your protected health information to you or your personal representative (someone with the legal right to make health decisions for you).
  • As Required by Law. We must disclose protected health information about you when required to do so by law. Public Health Activities. We may disclose your protected health information to public health agencies for reasons such as preventing or controlling disease, injury, or disability.
  • Victims of Abuse, Neglect or Domestic Violence. We may disclose your protected health information to government agencies about suspected abuse, neglect, or domestic violence.
  • Health Oversight Activities. We may disclose protected health information to government oversight agencies (i.e., state insurance departments, U.S. Department. of Health and Human Services) for activities authorized by law, audit, investigations, or civil or criminal proceedings.
  • Judicial and Administrative Proceedings. We may disclose protected health information in response to a court or administrative order. We may also disclose protected health information about you in certain cases in response to a subpoena, discovery request or other lawful process.
  • Law Enforcement. We may disclose protected health information under limited circumstances to a law enforcement official in response to a warrant or similar process; to identify or locate a suspect; or to provide information about the victim of a crime.
  • Coroners or Funeral Directors. We may release protected health information to coroners, medical examiners, and/or funeral directors as necessary to allow them to carry out their duties.
  • Under certain circumstances, we may disclose protected health information about you for research purposes, provided certain measures have been taken to protect your privacy.
  • To Avert a Serious Threat to Health or Safety. We may disclose protected health information about you, with some limitations, when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person.
  • Special Government Functions. We may disclose information as required by military authorities or to authorized federal officials for national security and intelligence activities.
  • Workers’ Compensation. We may disclose protected health information to the extent necessary to comply with state law for workers’ compensation programs.
  • Disaster Relief Efforts. We may use or disclose your protected health information to an authorized public or private entity to assist in disaster relief efforts. You may have the opportunity to object unless it would impede our ability to respond to emergency circumstances.
  • Coroners, Medical Examiners and Funeral Directors. We may disclose protected health information consistent with applicable law to coroners, medical examiners, and funeral directors only to the extent necessary to assist them in carrying out their duties.
  • Organ and Tissue Donation. We may disclose protected health information consistent with applicable laws to organizations that handle organ, eye or tissue donation or transplantation, only to the extent necessary to help facilitate organ or tissue donation or transplantation.
  • Research. Under certain circumstances, we may also use and disclose information about you for research purposes. All research projects are subject to a special approval process through an appropriate committee.
  • Correctional Institutions. If you are or become an inmate of a correctional institution or are in the custody of a law enforcement official, we may disclose to the institution or law enforcement official information necessary for the provision of health services to you, your health and safety, the health and safety of other individuals and law enforcement on the premises of the institution and the administration and maintenance of the safety, security and good order of the institution.
  • Family and Friends. We may disclose your protected health information to a family member or friend who is involved in your medical care or to someone who helps pay for your care. We may also use or disclose your protected health information to notify (or assist in notifying) a family member, legally authorized representative, or other person responsible for your care of your location, general condition, or death. If you are a minor, we may release your protected health information to your parents or legal guardians when we are permitted or required to do so under federal and applicable state law.

 

By Authorization or Consent

If we wish to use or disclose your health information for a purpose not set forth in this Notice, we will seek your authorization or written consent. Specific examples of uses and disclosures of health information requiring your authorization include: (i) most uses and disclosures of your health information for marketing purposes; (ii) disclosures of your health information that constitute the sale of your health information; and (iii) most uses and disclosures of psychotherapy notes (private notes of a mental health professional kept separately from a medical record). You may revoke an authorization or written consent in writing at any time, except to the extent that we have already taken action in reliance on your authorization.

We may not use or disclose your health information in response to a request associated with a civil, criminal, administrative, or legislative proceeding related to substance use disorder treatment records received from programs subject to 42 C.F.R. Part 2, or testimony relaying the content of such records, unless we have written consent or a court order after notice and an opportunity to be heard is provided to you or the holder of the record, as provided in 42 C.F.R. Part 2. For purposes of health information protected by 45 C.F.R. Part 2, if we obtain a court order authorizing the use or disclosure of such records or testimony, we must also obtain a subpoena or other legal requirement compelling disclosure before the request is completed. As provided un 42 C.F.R. Part 2, a patient may provide a single consent for all future uses or disclosures for treatment, payment, and health care operations purposes. Records that are disclosed to a part 2 program, covered entity, or business associate pursuant to the patient’s written consent for treatment, payment, and health care operations may be further disclosed by that part 2 program, covered entity, or business associate, without the patient’s written consent, to the extent the HIPAA regulations permit such disclosure.

 

Under federal and state law, certain kinds of PHI may require enhanced privacy protections. These forms of PHI include information pertaining to:

  • HIV/AIDS testing, diagnosis, or treatment
  • Venereal and /or communicable Disease(s)
  • Genetic Testing
  • Alcohol and drug abuse prevention, treatment, and referral
  • Psychotherapy notes
  • Reproductive Health Information

 

We will only disclose this type of information when permitted or required by law or upon your prior written authorization.

 

Uses and disclosures of protected health information for marketing purposes and disclosures that constitute marketing of protected health information require your written permission. If you provide us with authorization to use or disclose health information about you, you may revoke that authorization, in writing, at any time. If you revoke your authorization, we will no longer use or disclose health information about you for the reasons covered by your written authorization. However, we are unable to take back any disclosures we have already made with your permission, and we are required to retain our records of the care that we provided to you.

Your Rights Regarding Your Protected Health Information

You have certain rights regarding protected health information we maintain about you.

  • Right to Access Your Protected Health Information. You have the right to review or obtain copies of your protected health information records, with some limited exceptions. Usually the records include enrollment, billing, claims payment and case or health management records. Your request to review and/or obtain a copy of your protected health information must be made in writing. We may charge a fee for the costs of producing, copying, and mailing your requested information, but we will tell you the cost in advance. The form to Request Access to PHI (AV014369) is available at the link below.
  • Right to Amend Your Protected Health Information. If you feel that your protected health information maintained by us is incorrect or incomplete, you may request that we amend the information. Your request must be made in writing and must include the reason you are seeking a change. We may deny your request, if for example, you ask us to amend information that was not created by us, or you ask us to amend a record that is already accurate and complete. If we deny your request to amend, we will notify you in writing. You then have the right to submit to us a written statement of disagreement with our decision, and we have the right to rebut that statement. The form to Request an Amendment to PHI (AV014367) is available at the link below.
  • Right to an Accounting of Disclosures. You have the right to request an accounting of disclosures we have made of your protected health information. The list will not include our disclosures related to your treatment, our payment or health care operations, or disclosures made to you or with your authorization. The list may also exclude certain other disclosures, such as for national security purposes. Your request for an accounting of disclosures must be made in writing and must state a time period for which you want an accounting. This time period may not be longer than six years and may not include dates before April 14, 2003. Your request should indicate in what form you want the list (paper or electronically). For additional lists within the same time period, we may charge a fee for providing the accounting, but we will tell you the cost in advance. The form to Request an Accounting of Disclosure (AV014370) is available at the link below.
  • Right to Request Restrictions on the Use and Disclosure of Your Protected Health Information. You have the right to request that we restrict or limit how we use or disclose your protected health information for treatment, payment, or health care operations. If we do agree, we will comply with your request unless the information is required by law or needed for an emergency. Your request for a restriction must be made in writing. In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit how we use or disclose your information, or both; and (3) to whom you want the restrictions to apply. The form to Request Restrictions (AV014366) is available at the link below.
  • Right to Receive Confidential Communications. You have the right to request that we use a certain method to communicate with you or that we send information to a certain location if the communication could endanger you. Your request to receive confidential communications must be made in writing. Your request must clearly state that all or part of the communication from us could endanger you. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted. The form to Request Confidential Communication (AV014368) is available at the website link below.
  • Right to a Paper Copy of This Notice. You have a right at any time to request a paper copy of this Notice, even if you had previously agreed to receive an electronic copy. You may obtain a copy of this notice at the link below.
  • Contact Information for Exercising Your Rights. You may exercise any of the rights described above by contacting our Privacy Office. See the end of this Notice for the contact information, or obtain the forms at the link below

 

Health Information Security and Notification to you of a Breach of your Unsecure PHI

Avēsis ACE requires its employees and third-party vendors to follow its security policies and procedures that limit access to health information about members to those employees who need it to perform their job responsibilities. In addition, we maintain physical, administrative, and technical security measures to safeguard your protected health information. Although we take these steps to protect your PHI, we are required to notify you of a breach of unsecured protected health information.

 

Changes to This Notice

We reserve the right to change the terms of this Notice at any time, effective for protected health information that we already have about you as well as any other information that we receive in the future. We will provide you with a copy of the new Notice whenever we make a material change to the privacy practices described in this Notice. Any time we make a material change to this Notice, we will promptly revise and issue the new Notice with the new effective date.

Complaints

If you are concerned that we have violated your privacy rights, or you disagree with a decision we made about access to your records, you may file a complaint with us by contacting the privacy office listed below. You may also send a written complaint to the U.S. Department of Health and Human Services. The privacy office listed below can provide you with the appropriate address upon request. We support your right to protect the privacy of your protected health information. We will not retaliate against you or penalize you for filing a complaint.

Our Legal Duty

We are required by law to protect the privacy of your information, provide this notice about our information practices, and follow the information practices that are described in this Notice.

If you have any questions or complaints, please contact:

 

Attn: Privacy Office

Avēsis, LLC

1295 W Washington St Suite 212 Tempe, AZ 85288

Email: privacyoffice@avesis.com

Phone Number: 855-214-6777

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