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Your Rights With Respect to Protected Health Information

You have the following rights regarding Protected Health Information we maintain about you:

 Right to Inspect and Copy. You have the right to inspect and obtain a copy of Protected Health Information about you that may be used to make decisions about your Plan benefits. To inspect and copy Protected Health Information that may be used to make such decisions about you, you must submit your request in writing to the Privacy Official. If you request an electronic copy, we will provide it to you if the Protected Health Information is maintained electronically and is readily producible or, if it is not readily producible, we will provide it in a mutually-agreed, readable, electronic form and format. If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other supplies associated with your request.

We may deny your request to inspect and copy in certain circumstances. If you are denied access to Protected Health Information, you may make a written request that the denial be reviewed, addressed to the Privacy Official.

Right to Amend. You have the right to request an amendment of Protected Health Information about you for as long as the information is kept by or for the Plan. To request an amendment, your request must be made in writing and submitted to the Privacy Official. In the written request, you must provide a reason that supports your request.

We may deny your request for an amendment if it is not in writing or does not include a reasonable basis for the request. In addition, we may deny your request if you ask us to amend information that: is not part of the Protected Health Information kept by or for the Plan; was not created by us, unless the person or entity that created the information is no longer available to make the amendment; is not part of the information which you would be permitted to inspect and copy; or is accurate and complete in our judgment.

Right to an Accounting of Disclosures. You have the right to request an accounting of disclosures of Protected Health Information about you, excluding disclosures: made to carry out payment or health care operations; incident to a use or disclosure otherwise permitted or required; authorized by you or made to you; for national security or intelligence purposes; to correctional institutions or law enforcement officials under applicable law; or as part of a “limited data set” as authorized by law.

To request an accounting of disclosures, you must submit your request in writing to the Privacy Official. Your request must state a time period which may not be longer than six years and may not include dates before April 14, 2004. Your request should indicate in what form you want the list (for example, paper or electronic). The first list you request within a 12-month period will be free. For additional lists, we may charge you for the costs of providing the list. We will notify you of the cost involved, and you may choose to withdraw or modify your request at that time before any costs are incurred.

Right to Request Restrictions. You have the right to request a restriction or limitation on the Protected Health Information we use or disclose about you for payment or health care operations. You also have the right to request a limitation on the Protected Health Information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend. For example, you could ask that we not use or disclose information about a surgery you had.

We will comply with any restriction request if: (1) except as otherwise required by law, the disclosure is to the health plan for purposes of carrying out payment or health care operations (and is not for purposes of carrying out treatment); and (2) the protected health information pertains solely to a health care item or service for which the health care provider involved has been paid out-of- pocket in full.

To request restrictions, you must make your request in writing to the Privacy Official. In your request, you must tell us, specifically: (1) what information you want to limit; whether you want to limit our use, disclosure or both; and (3) to whom you want the limits to apply, for example, disclosures to your spouse. We will attempt to honor such request if, in our sole discretion, the request is reasonable.

Right to Request Confidential Communications. You have the right to request that we communicate with you about Protected Health Information about you by alternative means or at alternative locations. For example, you can ask that we only contact you at work or by mail.

To request confidential communications, you must make your request in writing to the Privacy Official. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.

Right to be Notified of a Breach. You have the right to be notified in the event that we (or a Business Associate) discover a breach of unsecured protected health information.

Right to a Paper Copy of This Notice. You have the right to a paper copy of this Notice. You may ask us to give you a copy of this Notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this Notice. To obtain a paper copy of this Notice, please contact the Plan’s Privacy Officer - the Executive Director of Employee Experience at 336-832-8740.

Changes to this Notice

We reserve the right to change this Notice. We reserve the right to make the revised or changed Notice effective for medical information we already have about you as well as any information we receive in the future. The Notice will contain on the first page, at the top, the effective date.

Complaints

If you believe your privacy rights as described in this Notice have been violated, you may file a complaint with the Plan or with the Office for Civil Rights. To file a complaint with the Plan, contact the Plan’s Privacy Officer at 336-832-8740. All complaints must be submitted in writing. You will not be penalized, or in any other way retaliated against, for filing a complaint.