Health Information Disclosure – Privacy Practices
Notice of Health Information Privacy Practices
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 Privacy Notice is provided to you in connection with your health plan [see list below] from one of the following affiliated insurance companies (collectively referred to as “we” or “us”):
Monumental Life Insurance Company
Stonebridge Life Insurance Company
Transamerica Financial Life Insurance Company
Transamerica Life Insurance Company
Health Plans: This Notice applies only to Prescription Drug Coverage, Student Health, Dental, Medicare Supplement, Retiree Medical, Champus/Tricare, Long Term Care, Home Health Care, Nursing Home, Extended Hospital Expense Rider, Major Medical, Excess Major Medical, Supplemental Medical and Limited Benefits.
Effective Date: This Notice is effective April 14, 2009
Our Commitment to Your Privacy
Maintaining the privacy of your protected health information is a high priority to us. In conducting our business, we will create records regarding you and the services we provide to you. We are required by law to maintain the confidentiality of your protected health information and to provide you with notice of our legal duties and privacy practices with respect to your protected health information. We will abide by the terms of this Notice of Privacy Practices so long as it remains in effect.
We reserve the right to change our privacy practices and apply the changes to any protected health information received or maintained by us prior to the date of such change. If a privacy practice is materially changed, we will provide you with a revised Notice of Privacy Practices. In the event applicable law prohibits or materially limits the use or disclosure of your protected health information; we will comply with the more stringent law. You may request a paper copy of our most current notice at any time by contacting Customer Service at 1-800-752-9797. If you have requested a copy of this Notice by e-mail or other electronic means, you also have the right to request a paper copy at any time.
USES AND DISCLOSURES OF YOUR PROTECTED HEALTH INFORMATION
Your Authorization. Except as outlined below, we will not use or disclose your protected health information for any purpose unless you have signed a form authorizing the use or disclosure. You have the right to revoke that authorization in writing unless we have taken any action in reliance on the authorization.
We May Use and Disclose Your Health Information in the Following Ways:
- Treatment. We will make disclosures of your protected health information as necessary for your treatment. For instance, a doctor or health care facility involved in your care may request certain of your protected health information that we hold in order to make decisions about your care.
- Payment. We will make uses and disclosures of your protected health information as necessary for payment purposes. For instance, we may use information regarding your medical procedures and treatment to process and pay claims, to determine whether services are medically necessary or to otherwise pre-authorize or certify services as covered under your health plan. We may also forward such information to another health plan, which may also have an obligation to process and pay claims on your behalf.
- Health Care Operations. We will use and disclose your protected health information as necessary, and as permitted by law to operate our business including performing quality improvement and assurance, conducting cost-management and business planning, enrollment, underwriting, reinsurance, compliance auditing, rating, and other functions related to your health plan.
- Family and Friends Involved in Your Care. With your approval, we may disclose your protected health information to designated family, friends, and others who are involved in your care or in the payment for your care. If you are unavailable, incapacitated, or facing an emergency medical situation, and we determine that a limited disclosure may be in your best interest, we may share limited protected health information without your approval.
- Business Associates. Certain aspects and components of our services are performed through contracts with outside persons or organizations, such as auditing, accreditation, actuarial services, legal services, etc. We may use and disclose your protected health information to one or more of these outside persons or organizations who assist us with our health care operations. In all cases, we require these business associates to appropriately safeguard the privacy of your protected health information.
- Information Received Pre-Enrollment. We may request and receive from you and your health care providers protected health information prior to the issuance of a certificate or policy of insurance to you and to determine your rates. We will protect the confidentiality of that information in the same manner as all other protected health information we maintain; and, if a certificate or policy of insurance is not issued to you, we will not use or disclose the information about you we obtained about you for any other purpose.
- Plan Sponsors. We may also use or disclose protected health information to the plan sponsor of a group health plan, if applicable, provided that any such plan sponsor certifies that the information provided will be maintained in a confidential manner and not used for employment related decisions or for other employee benefit determinations or in any other manner not permitted by law.
- Health-Related Benefits and Services. We or our business associates may also contact you regarding health-related benefits and services that may be of interest to you.
USE AND DISCLOSURE OF YOUR PROTECTED HEALTH INFORMATION IN CERTAIN SPECIAL CIRCUMSTANCES
Your protected health information may be used or disclosed as applicable without your authorization in the following circumstances: for any purpose when required by law; for public health activities as required by law if we suspect child abuse or neglect or believe you to be a victim of abuse, neglect, or domestic violence; as required by law for governmental health oversight agency conducting audits, investigations or civil or criminal proceedings; if required by a court or an administrative ordered subpoena or discovery request (in most cases you will have notice of such disclosure); as required by law for certain law enforcement purposes; about deceased persons to coroners, health examiners, and funeral directors consistent with law; if necessary for organ and tissue donation or transplant; for certain government-approved research purposes; upon reasonable belief to avert a serious threat to health or safety; for specialized government functions (such as military personnel and inmates in correctional facilities); national security or intelligence activities or to workers’ compensation agencies if necessary to make a benefit determination.
Your Privacy Rights
You have the following rights as an individual with respect to the protected health information we maintain about you:
Confidential Communications. You may request that we communicate with you about your health and related issues in a particular manner or at a certain location. For instance, you may wish to receive communications from us at your work location rather than your home. We will evaluate all such requests, however, we must only accommodate your written request if you clearly state that your life could be endangered by the disclosure of all or part of your protected health information. You may obtain a form to request to receive confidential communication in a particular manner or at a certain location by contacting Customer Service at 1-800-752-9797.
Access to Your Protected Health Information. You have a right to inspect and/or copy much of the protected health information that we retain on your behalf. We may charge a fee for the costs of copying, mailing, postage, labor and supplies associated with your request and you will be notified in advance of any such fee to be charged. You may obtain an access request form by contacting Customer Service at 1-800-752-9797.
Requesting Restrictions. You have the right to request a restrictions on certain of our uses and disclosures of your protected health information for treatment, payment, or health care operations by notifying us of your request for a restriction in writing. Your request must describe in detail the restriction you are requesting. We will evaluate all requests for restrictions; however, we are not required to agree to the restriction and we retain the right to terminate an agreed to restriction if we believe such termination is appropriate. In the event of a termination by us, we will notify you of such termination. You also have the right to terminate, in writing or orally, any agreed- to restriction to sending such termination notice. You may obtain a form to request a restriction or to terminate an existing restriction by contacting Customer Service at 1-800-752-9797.
Amendment. You have the right to request in writing that protected health information that we maintain about you be amended or corrected. We are not obligated to make all requested amendments but will give each request careful consideration. All amendment requests, in order to be considered by us, must be in writing, signed by you or your representative, and must state the reasons for the amendment/correction request. If an amendment or correction you request is made by us, we may also notify others who work with us and have copies of the uncorrected record if we believe that such notification is necessary. You may obtain an amendment request form by contacting Customer Service at 1-800-752-9797.
Accounting of Disclosures. You have the right to receive an accounting of certain disclosures made by us of your protected health information. Requests must be made in writing and signed by you or your representative. Accounting request forms are available from Customer Service at 1-800-752-9797. The first accounting in any 12-month period is free;, but we may charge you for additional lists within the same 12-month period (you will be notified in advance of any fee to be charged).
Complaints. If you believe your privacy rights have been violated, you can file a complaint in writing. Send your complaint to: Consumer Affairs Department, 2700 W. Plano Parkway-3D, Plano, Texas 75075. You may also file a complaint with the Secretary of the U.S. Department of Health and Human Services in Washington D.C. in writing within 180 days of a violation of your rights. We will not retaliate against you for filing a complaint.
Additional Information
If you have any questions or need further assistance regarding this Notice, you may contact our Consumer Affairs Department at 1-972-881-6688.
Rev 1/2009
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