HEALTH
INSURANCE PORTABILITY AND ACCOUNTABILITY ACT
Eateries, Inc. Health Plan
INFORMATION
PRIVACY NOTICE
Original Date: April, 2004
Revision Date:
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.
The Health Insurance Portability and Accountability Act of 1996 (HIPAA)
grants you certain privacy rights with respect to the Health Information about
you that is maintained by the Eateries, Inc. Health Plan (the Plan). In addition, HIPAA requires that the Plan
comply with rules designed to protect this information from improper uses and
disclosures. One of your rights under
HIPAA is to know how the Plan handles your Health Information. This Notice is designed to explain how the
Plan uses and discloses your Health Information, and what rights you have with
respect to your Health Information. This
Privacy Notice applies to all plans sponsored by Eateries, Inc. that qualify as
covered entities under HIPAA. Therefore,
the terms “Plan,” and “Benefits Coordinator” must be
construed to apply to all the plans in which you are a participant.
If you have any questions about this notice, please contact the
Eateries, Inc. Health Plan’s Privacy Officer,
WHO SEES MY
HEALTH INFORMATION?
The Eateries, Inc. Benefits Coordinators include all Individuals who
must see health related information that can be linked to an Individual
(“Protected Health Information”) in order to operate the Plan. Benefits Coordinators are members of the
Eateries, Inc. staff. However, certain
employees of outside businesses help operate the Plan as well and
necessarily receive and use Health Information.
Collectively, this notice refers to all individuals authorized to receive,
use, or disclose Protected Health Information as the Plan Administration
Group. Any member of the Plan
Administration Group must complete training about privacy and security
procedures. Each member of the Group understands
that a violation of the Plan’s privacy and security procedures may result in
sanctions, penalties, or even prison sentences.
Therefore, Group members take the privacy of your information very
seriously.
OUR PROMISE
TO YOU
As Plan Administration Group members of the Eateries, Inc. Health Plan,
we understand that your health and medical information is private
information. Eateries, Inc. is
100 percent committed to using the Health Information we obtain about you
only for the purposes of paying benefits, operating the plan, and as expressly
permitted or Required by Law. We will only use the Protected Health
Information we obtain for a different purpose if you expressly authorize us to
do so.
HOW WE USE
AND DISCLOSE
THE HEALTH INFORMATION WE OBTAIN
Group members only use and disclose Protected Health Information in ways
that are expressly permitted by HIPAA.
The sections entitled Treatment, Payment and Health Care Operations
describe how we might use and disclose the Health Information we obtain about
you (your “Health Information”). Some of
these uses and disclosures are routine, and are necessary in order to run the
plan, and to provide assistance to the health care providers who treat
you. Others are not routine, but are Required by Law or necessary due to special circumstances. The disclosures listed here are merely
examples of ways in which the plan could use or disclose your health
information; the plan does not necessarily fulfill each of these functions for
all qualifying health plans. The Plan
has developed procedures for all of these uses and disclosures.
Treatment. Group members
may use or disclose your Health Information to facilitate medical Treatment or
services by your health care providers such as doctors, nurses, technicians,
medical students, other hospital personnel or pharmacists who are involved in
taking care of you. For example, we
might disclose information about recent prescription medications or surgical
procedures to an emergency room doctor, if he or she requested it in order to
provide you the best emergency Treatment.
Payment. Group members
may use and disclose your Health Information in order to determine your
eligibility for Plan benefits, to process claims for Payment for your
Treatment, or to determine whether any other plan or party might be responsible
for paying for the Treatment. For
example, a Group member could review Health Information about you that is contained on a bill in the process of assisting you with
receiving benefits from insurance providers or third-party administrators. These are just some examples of how the Plan
might use and disclose your Health Information in order to make sure the Plan
pays benefits properly.
Health Care
Operations. Group members may use and disclose your
Health Information in order to run the Plan.
For example, we may review your Health Information in order to:
1. Conduct
quality assessment and improvement activities;
2. Perform
underwriting, premium rating, and other activities relating to Plan coverage;
3. Submit
claims for stop loss (or excess loss) coverage;
4. Conduct
or arrange for medical review, legal services, audit services, and fraud and
abuse detection programs;
5. Learn
about the successes and failures of the Plan, and about ways to manage costs;
and to
6. Manage
the business of the Plan and make sure it is administered properly and
effectively.
Required By
Law. Group members will disclose your Health
Information when required to do so by federal, state or local law. For example, we will disclose information
about medical bills submitted by your health care provider pursuant to a court
order in a litigation proceeding alleging that the provider has fraudulent
billing practices.
To Prevent Serious Threats to Health or
Safety. We may use and disclose your Health
Information in order to prevent a serious threat to your health and safety or
the health and safety of the public or another person. Any such disclosure would only be to a person
who is able to help prevent the threat.
SPECIAL
SITUATIONS
Disclosures to Eateries, Inc. Employees who are
not Group Members. If an employee of
Eateries, Inc. who is not a member of the Plan Administration Group requests
information from the Plan for purposes of modifying, amending or terminating
the Plan, or in order to obtain premium bids from health plans for providing
health insurance coverage, Group members may provide that employee “Summary
Health Information.” Summary Health
Information summarizes the claims history, claims expenses or type of claims
experienced by Plan participants, and is redacted to eliminate information that
identifies Individual participants.
In addition, Group members may disclose to such employees information
about whether an Individual is participating in the Plan or is enrolled in or
has disenrolled from a fully insured benefit offered by the Plan.
Organ and
Tissue Donation. If you are an organ donor, we may release
your Health Information to organizations that handle organ procurement or
organ, eye or tissue transplantation or to an organ donation bank, in order to
facilitate organ or tissue donation and transplantation.
Military and
Veterans. If you are a member of the armed forces of
the
Workers’
Compensation. Group members may release your Health
Information if required to in order to comply with workers’ compensation laws.
Public Health
Risks. We may disclose your Health Information for
public health activities, which generally include the following:
1. To
prevent or control disease, injury or disability;
2. To
report births and deaths;
3. To
report child abuse or neglect;
4. To
report reactions to medications or problems with products;
5. To
notify people of recalls of products they may be using;
6. To
notify a person who may have been exposed to a disease or may be at risk for
contracting or spreading a disease or condition;
7. To
notify the appropriate government authority if the Group member believes that
you have been the victim of abuse, neglect or domestic violence, and you agree
to the disclosure, or the disclosure is Required by
Law.
Health
Oversight Activities. We may disclose your Health Information to a
Health Oversight Agency for activities authorized by Law. These oversight activities include, for
example audits, investigations, inspections, and licensure. These activities are necessary for the
government to monitor the health care system, government programs, arid compliance with civil rights laws.
Lawsuits and Disputes. If you are
involved in a lawsuit or a dispute, we may disclose your Health Information in
response to a court or administrative order.
Group members may also disclose your Health Information in response to a
subpoena, discovery request, or other lawful process by someone else involved
in the dispute, but only if efforts have been made to tell you about the
request or to obtain an order protecting the information requested.
Law
Enforcement. If asked to do so by a Law Enforcement Official,
a Group member may release your Health Information under the following
circumstances:
1. In response to a court order, subpoena, warrant, summons or
similar process;
2. To
identify or locate a suspect, fugitive, material witness, or missing person;
3. About
the victim of a crime if, under certain limited circumstances, the Group member
is unable to obtain the person’s agreement;
4. About a death the Privacy Officer or his or her designee
believes may be the result of criminal conduct;
5. About
criminal conduct at a hospital; and
6. In
emergency circumstances to report a crime; the location of the crime or
victims; or the identity, description or location of the person who committed
the crime.
Coroners,
Medical Examiners and Funeral Directors. We may release
your Health Information to a coroner or medical examiner. This may be necessary, for example, to
identify you if you die or to determine the cause of your death. We may also release your Health Information
to funeral directors as necessary to carry out their duties.
National
Security and Intelligence Activities. Group members may release your
Health Information to authorized federal officials for intelligence,
counterintelligence, and other national security activities authorized by law.
Inmates. If you are an
inmate of a correctional institution or under the custody of a Law Enforcement
Official, we may release your Health Information to the correctional
institution or Law Enforcement Official.
This release would be necessary (i) for the institution to provide
you with health care; (ii) to protect your health and safety or the health
and safety of others; or (iii) for the safety and security of the
correctional institution.
YOUR RIGHTS
REGARDING THE HEALTH
INFORMATION ABOUT YOU THAT WE MAINTAIN
You have the following rights regarding the Health Information that the
Plan maintains about you:
Right to
Inspect and Copy. You have the right to inspect and copy your
Health Information that may be used to make decisions about your Plan
benefits. To inspect and copy medical
information that may be used to make decisions about you, you must complete the
Form entitled “Request for Access to Protected Health Information” and submit
the Form to the Privacy Officer. If you
request a copy of the information, you may be charged a fee for the costs of
copying, mailing or supplies associated with your request. The form is available from the Privacy
Officer.
Your request to inspect and copy may be denied in certain very limited
circumstances. If you are denied access
to medical information, you may request that the denial be reviewed.
Right to
Amend. If you feel that medical information the Plan
has about you is incorrect or incomplete, you may ask the Plan to amend the
information. You have the right to
request an amendment for as long as the information is kept by or for the Plan.
To request an amendment, you must complete a Form entitled “Request for
Amendment of Protected Health Information.”
This Form is available upon request from the Privacy Officer. Your request for an amendment may be denied
if you do not complete this Form. In
addition, your request may be denied if you ask us to amend information that:
1. Is
not part of the medical information kept by or for the Plan;
2. Was
not created by the Plan unless the person or entity that created the
information is no longer available to make the amendment;
3. Is
not part of the information which you would be permitted to inspect and a copy;
or
4. Is accurate and complete.
Right to an
Accounting of Disclosures. You have the right to request an “accounting
of disclosures” where such disclosure was made for any purpose other than
Treatment Payment, or Health Care Operations.
To request this list or accounting of disclosures, you must complete the
Form entitled “Request for an Accounting of Disclosures of Protected Health
Information” and submit the Form to the Privacy Officer. Your request must state a time period which
may not be longer than six (6) years and may not include dates before
April, 2004. Your request should
indicate in what form you want the list (for example, paper or
electronic). This first list you request
with a twelve (12)‑month period will be
free. If additional lists are requested,
the Plan may charge you for the costs of providing the lists. You will be notified 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 medical information the Plan uses or discloses about you
for Treatment, Payment or Health Care Operations. You also have the right to request a limit on
the medical information the Plan discloses 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 previous surgery you had to your spouse, even
though your spouse is involved in the Payment for a related surgery.
The Plan is not required to agree to your request.
To request restrictions, you must complete the Form entitled “Request
for Restriction of Protected Health Information” and submit it to the Privacy
Officer.
Right to
Request Confidential Communications. If you believe that the normal
form of communications of benefit information could endanger you, you have the
right to request that the Plan communicate with you about medical matters in a
certain way or at a certain location.
For example, you can ask that we only contact you at work or by mail.
To request confidential communications, you must complete the Form
entitled “Request for Confidential Communications of Protected Health
Information” and submit it to the Privacy Officer. The Plan will not ask you the reason for your
request and will accommodate all reasonable requests. Your request must specify how or where you
wish to be contacted.
Right to a
Paper Copy of This Notice. You may obtain an electronic copy of this
notice at the following address, under the section entitled Company
Information: www.eats-inc.com. You also have
the right to a paper copy of this notice.
You may request a copy of this notice at any time, and you may obtain a
copy by contacting the Privacy Officer.
CHANGES TO THIS NOTICE
The Plan reserves the right to change this notice. The Plan reserves 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. A copy of the current notice will be posted
on the Eateries, Inc. website, if the website includes a description of the
Plan. The notice will contain on the
first page, in the top left hand corner, the effective date.
COMPLAINTS
If you believe your privacy rights have been violated, you may file a
complaint with the hospital or with the Secretary of the Department of Health
and Human Services. To file a complaint
with the Plan, contact the Privacy Officer,
You will not be penalized or retaliated against for filing a complaint.
OTHER USES
OF MEDICAL INFORMATION
Other uses and disclosures of medical information not covered by this
notice or the laws that apply to the Plan will be made only with your written
authorization. If you provide the Plan
authorization to use or disclose medical information about you, you may revoke
that authorization, in writing, at any time.
If you revoke your authorization, the Plan will no longer use or
disclose medical information about you for the reasons covered by your written
authorization. You understand that the
Plan is unable to take back any disclosures already made with your
authorization.