Notice of Privacy Practices for Protected Health 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.
This Notice of Privacy Practices describes the practices of Health One Alliance, LLC, for safeguarding individually identifiable protected
health information. The terms of this Notice apply to members and dependents for their individual and group health insurance. This
Notice is effective March 23, 2013.
We are required by law to maintain the privacy of our members' and dependents' protected health
information, provide notice of our legal duties and privacy practices with respect to protected health information and notify affected
individuals of a breach of their unsecured identifiable protected health information. We are required to abide by the terms of this
Notice as long as it remains in effect. We reserve the right to change the terms of this Notice as long as it remains in effect. We
reserve the right to change the terms of this Notice as necessary and to make the new Notice effective for all protected health information
maintained by us. You have the right to request a paper copy of the Notice by sending your request to: Privacy Officer, Health One
Alliance, LLC, 1503 N. Tibbs Rd, Dalton, GA 30720.
Uses and Disclosures of Your Protected Health Information Authorization. Except
as explained below, we will not use or disclose your protected health information for any purpose unless you have signed a form authorizing
our use or disclosure, including most uses and disclosures of psychotherapy notes, uses and disclosures for marketing purposes and
disclosures for sale of protected health information. Unless we have taken any action in reliance on the authorization, you have the
right to revoke an authorization if the request for revocation is in writing and sent to: Privacy Officer, Health One Alliance, LLC,
1503 N. Tibbs Rd, Dalton, GA 30720. A form to revoke an authorization can be obtained from the Health Information Protection Officer.
Disclosures for Treatment. We may disclose your protected health information as necessary for your treatment. For instance, a doctor
or healthcare facility involved in your care may request your protected health information in our possession to assist in your care.
Uses and Disclosures for Payment. We use and disclose your protected health information as necessary for payment purposes. For instance,
we may use your protected health information to process or pay claims, for subrogation, to perform a hospital admission review to
determine whether services are for medically necessary care or to perform prospective reviews. We may also disclose information to
another insurer in order to process or pay claims on your behalf.
Uses and Disclosures for Health Care Operations. We use and disclose
your protected health information as necessary for health care operations. For instance, we may use or disclose your protected health
information for quality assessment and quality improvement, credentialing health care providers, premium rating, conducting or arranging
for medical review or compliance. We may also disclose your protected health information to another insurer, health care facility
or health care provider for activities such as quality assurance or case management. We may contact your health care providers concerning
prescription drug or treatment alternatives.
Genetic Information Non-discrimination Act. We are prohibited from using your genetic
information for underwriting purposes. Genetic information for purposes of the underwriting means, with respect to any individual,
information about (i) such individual's genetic tests, (ii) the genetic tests of family members of such individual, and (iii) the
manifestation of a disease or disorder in family members of such individual (i.e., family medical history). It also includes the collection
of genetic information for clinical research purposes, but excludes information about the sex or age of any individual.
Information
Received Pre-enrollment. We may request and receive from you and your health care providers' protected health information prior to
your enrollment under the group health insurance policy. We will use this information to determine whether you are eligible to enroll
under the policy and to determine the premium rates. If you do not enroll, we will not use or disclose the information we obtained
about you for any other purpose. Information provided on enrollment forms or applications will be utilized for all coverages being
applied for, some of which may be protected by the state, not federal, privacy laws.
Business Associates. Certain aspects and components
of our services are performed by third party persons or organizations pursuant to agreement or contract with us. It may be necessary
for us to disclose your protected health information to these third party persons or organizations that perform services on our behalf.
We require them to appropriately safeguard the privacy of your protected health information as required by law.
Family, Friends and
Personal Representatives. With your written authorization, we may disclose to family members, close personal friends, or another person
you identify, your protected health information relevant to their involvement with your care or paying for your care. If you are unavailable,
incapacitated or involved in an emergency situation, and we determine that a limited disclosure is in your best interests, we may
disclose your protected health information to such persons without your approval. We may also disclose your protected health information
to public or private entities to assist in disaster relief efforts.
Other Uses and Disclosures. We are permitted or required by law
to use or disclose your protected health information, without your authorization, in the following circumstances:
• For any
purpose required by law;
• For public health activities (for example, reporting of disease, injury, birth, death or suspicion
of child abuse or neglect);
• To a governmental authority if we believe an individual is a victim of abuse, neglect or domestic
violence;
• For health oversight activities (for example, inspections, licensure actions or civil, administrative or criminal
proceedings or actions);
• For judicial or administrative proceedings (for example, pursuant to a court order, subpoena or discovery
request);
• For law enforcement purposes (for example, reporting wounds or injuries or for identifying suspects, witnesses or
missing people);
• To coroners and funeral directors;
• For procurement, banking or transplantation of organ, eye or tissue
donations;
• For certain research purposes;
• To avert a serious threat to health or safety under certain circumstances;
• For military activities if you are a member of the armed forces, for intelligence or national security issues; or about an
inmate or an individual to a correctional institution or law enforcement official having custody; and
• For compliance with
workers' compensation insurance purposes.
We will adhere to all applicable state and federal laws or regulations that provide additional
privacy protections. We will only use or disclose AIDS/HIV-related information, genetic testing information and information pertaining
to your mental condition or any substance abuse problems as permitted by state and federal law or regulation. Except for the types
of uses and disclosures of protected health information described in this Notice, we may make other uses and disclosures of protected
health information only with your written authorization.
Your Rights Regarding the Restriction on Use and Disclosure of Your Protected
Health Information. You have the right to request certain restrictions on how we use or disclose your protected health information
for treatment, payment or health care operations. You also have the right to request restrictions on disclosures to family members
or others who are involved in your care of the paying of your health care. To request a restriction, you must send a written request
to: Privacy Officer, Health One Alliance, LLC, 1503 N. Tibbs Rd, Dalton, GA 30720. A form to request a restriction can be obtained
from the Privacy Officer. We are not required to agree to your request for a restriction, except for a restriction to disclose your
protected health information to a health plan if the purpose is to carry out payment or health care operations which is not otherwise
required by law and the protected health information pertains solely to a health care item or service for which a person, other than
the health plan, has paid the health care provider in full. If we agree to your request for a restriction, you will receive a written
acknowledgement from us.
Receiving Confidential Communications of Your Protected Health Information. You have the right to request
communications regarding your protected health information from us by alternative means (for example by fax) or at alternative locations.
We will accommodate reasonable requests for such alternative means. To request a confidential communication, you must send a written
request to: Privacy Officer, Health One Alliance, LLC, 1503 N. Tibbs Rd, Dalton, GA 30720. A form to request a confidential communication
can be obtained from the Privacy Officer.
Access to Your Protected Health Information. You have the right to inspect and/or obtain
a copy of your protected health information we maintain in your designated record set, with a few exceptions. To request access, you
must send a written request to: Privacy Officer, Health One Alliance, LLC, 1503 N. Tibbs Rd, Dalton, GA 30720. A form to request access
to your protected health information can be obtained from the Privacy Officer. A fee will be charged to you for copying and postage.
Amendment of Your Protected Health Information. You have the right to request an amendment to your protected health information to
correct inaccuracies. To request an amendment, you must send a written request to: Privacy Officer, Health One Alliance, LLC, 1503
N. Tibbs Rd, Dalton, GA 30720. A form to request an amendment to your protected health information can be obtained from the Privacy
Officer. We are not required to grant the request in certain circumstances.
Accounting of Disclosures of Your Protected Health Information.
You have the right to receive an accounting of certain disclosures of your protected health information made by us after April 14,
2003, of your protected health information. To request an accounting, you must send a written request to: Privacy Officer, Health
One Alliance, LLC, 1503 N. Tibbs Rd, Dalton, GA 30720. A form to request an accounting of your protected health information can be
obtained from the Privacy Officer. The first accounting in any 12-month period will be free; however, a fee will be charged to you
for any subsequent request for an accounting during that same time period.
Complaints. If you believe your privacy rights have been
violated, you can send a written complaint to the Privacy Officer, Health One Alliance, LLC, 1503 N. Tibbs Rd, Dalton, GA 30720 or
to the Secretary of the U.S. Department of Health and Human Services. There will be no retaliation for filing a complaint.
If you
have any questions or need any assistance regarding this Notice or your privacy rights, you may contact the Customer Service Department
at Health One Alliance, LLC at 1-800-842.5758.