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for the Formed Fiber
Technologies, Inc. Health Plan
Effective Date: April 14, 2004
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.
You are receiving
this Notice of Privacy Practices (Notice) because you are enrolled in one
or more of the Formed Fiber Technologies, Inc. Self-Insured Health Plans
(“Health Plans”). Health Plans include medical and the health
flexible spending account. Health Plan is committed to protecting the
confidentiality of any health information it receives, maintains, uses or
discloses. This Notice describes how a Health Plan may use and disclose
your “protected health information” (PHI). PHI is any health information
that: (1) identifies the individual or may reasonably be used to identify
the individual; (2) is created or received by a health care provider,
health plan, employer or health care clearinghouse; and (3) relates to your
past, present or future physical or mental health condition, or provision
of or payment for health care.
Designated associates of Formed Fiber Technologies, Inc. (the
“Plan Sponsor”) who administer and manage the Health Plans may use your PHI
only for appropriate plan purposes (such as for payment or health care
operations), but not for employment-related purposes of the Plan Sponsor.
These designated associates must comply with the same requirements that
apply to a Health Plan to safeguard your PHI and protect the
confidentiality of PHI.
The Health Plans are required by the Health Insurance
Portability and Accountability Act of 1996 (HIPAA) to provide this Notice
to you. Additionally, each Health Plan is required by law to:
- Maintain the privacy of your protected health
information (PHI), and
- Follow the terms of its Notice of Privacy Practices
that is currently in effect.
For the purposes of HIPAA compliance, the Health Plan,
consisting of the Employee Welfare Benefit Plan (medical) and Health
Flexible Spending Account plan are intended to operate as an organized
health care arrangement (OHCA). This allows Formed Fiber to have one Notice
and one set of Policies and Procedures encompassing both self-insured plans
that are part of the OHCA.
If you have questions about any part of this Notice or if you
want more information about the privacy practices of the Health Plans,
please contact the Health Information Privacy Officer (Privacy Officer),
125 Allied Road, Auburn, ME 04211, 207-784-1135.
How
Your Protected Health Information (PHI) May be Used or Disclosed
A Health Plan is permitted by law to use and disclose your
protected health information (PHI) either pursuant to an authorization by
you, or in certain other ways, which are described below. Examples of
permitted uses and disclosures are included. This Notice does not list
every permitted use or disclosure the Health Plan may make. However, all
the ways a Health Plan is permitted to use or disclose PHI will fall within
one of the categories below.
1.
Treatment Purposes: A Health Plan may disclose PHI to a health care
provider for the health care provider’s treatment purposes, although it is
more likely a health care provider would receive your PHI from another
health care provider than from the Health Plan. For example, if your
Primary Care Physician or your treating medical provider refers you to a
specialist for treatment, the Health Plan can disclose your PHI so the
specialist to whom you have been referred so (s)he can become familiar with
your medical condition, prior diagnoses and treatment, and prognosis.
Examples of health care providers include doctors, nurses, and laboratory
technicians.
2.
Payment Purposes: A Health Plan may use or disclose your PHI to evaluate
and process any requests for coverage and claims for benefits you make, and
may review PHI included with claims to reimburse providers for treatment
and services rendered. Additionally, a Health Plan may disclose PHI to
another group health plan or to a health care provider for the payment
purposes of the Health Plan, the other group health plan, or the health
care provider. For example, Health Plan can disclose your PHI to another
health plan or payer for purposes of coordinating payment of benefits.
3. Health Care Operations Purposes: A Health Plan may use or disclose
your PHI for its own health care operations and may disclose PHI to another
group health plan, a health care provider, a medical group or a hospital
for the health care operations purposes of the Health Plan, or for certain
health care operations purposes of the other entities. Examples of the
Health Plan’s “health care operations” include underwriting, premium rating
and other activities related to plan coverage; conducting quality
assessment and improvement activities; submitting claims for stop-loss
coverage; conducting or arranging for medical review, legal services, audit
services, and fraud and abuse detection programs; and business planning,
management and general administration of the Health Plan.
A Health Plan may disclose PHI to other entities in the OHCA
for all health care operations of the OHCA, even if the other entities of
the OHCA do not have a relationship with you.
4.
To a Business Associate of the Health Plan: A Health Plan may disclose PHI to a
Business Associate of the Health Plan, if a valid Business Associate
Agreement is in place between the Business Associate and Health Plan. A
Business Associate is an entity that performs a function on behalf of the
Health Plan and that uses PHI in doing so, or provides services to the
Health Plan such as legal, actuarial, accounting, consulting or
administrative services. Examples of Business Associates include the Health
Plan’s Third-Party Administrator and broker.
5. To the Plan Sponsor: A Health Plan may disclose PHI to
the Plan Sponsor if the Plan Sponsor has amended its plan document as
required by the Privacy Rule, certified to the Health Plan as required by
the Privacy Rule, and established certain safeguards and firewalls to limit
the classes of employees who will have access to PHI and to limit the use
of PHI to plan purposes and not for non-permissible purposes. Any
disclosures to the Plan Sponsor must be for purposes of administering the
Health Plan. Examples include: for claims appeals to the Plan’s Benefits
Committee, for case management purposes, or to Human Resources
representatives of the Plan Sponsor who are assisting plan members in
getting their claims resolved.
The plan may also disclose enrollment/disenrollment
information to the Plan Sponsor, for enrollment or disenrollment purposes
only, and may disclose “summary health information” (as defined under the
HIPAA medical privacy regulations) to the Plan Sponsor for the purpose of
obtaining premium bids or modifying or terminating the plan.
6.
As Required by Law or Requested as Part of a Regulatory or
Legal Proceeding: A Health Plan may disclose PHI as required by law or
when requested as part of a regulatory or legal proceeding. For example, a
Health Plan may disclose medical information when required by a court order
in a litigation proceeding, or pursuant to a subpoena, or as necessary to
comply with Workers’ Compensation laws.
7.
For Public Health Activities or to Avert a Serious Threat to
Health or Safety: A Health Plan may disclose PHI to public health
authorities for purposes such as preventing or controlling diseases, injury
or disability; reporting to the Food and Drug Administration on products
and reactions to medications; and reporting disease or infection exposure.
8.
For Law Enforcement or Specific Government Functions: A Health Plan may disclose PHI to
law enforcement personnel for purposes such as identifying or locating a
suspect, fugitive, material witness or missing person; complying with a
court order or subpoena; and other law enforcement purposes.
9.
For Treatment Alternatives and Health-Related Benefits and
Services: A Health
Plan may use and disclose your PHI to tell you about possible treatment
options or alternatives and health-related benefits and services that may
be of interest to you.
10. To Individuals Involved in Your Care or
Payment for Your Care: A Health Plan may use and disclose your PHI to a
family member involved in, or who helps pay for, your health care. The
Health Plan will disclose general and/or payment-related information to
your spouse or parent (if you are a minor child), but will not disclose information
on your diagnosis or prognosis to your spouse unless you authorize the
release of such information. If you wish to make this authorization, you
can request a form to do so from the HR Department.
11. Additional Uses and Disclosures: Health Plan may also use or disclose
your PHI, in accordance with the law:
o To report abuse or neglect, or to report
domestic violence to appropriate agencies or authorities;
o To workers’ compensation carriers or plans,
to the extent necessary to comply with workers’ compensation laws;
o For judicial and administrative proceedings
(for example, to respond to court orders or subpoenas);
o To health oversight agencies or other
government agencies, for audits, investigations, inspections and licensure
needed for the government to monitor health plans;
o To facilitate organ or tissue donation or
transplantation, if you are an organ or tissue donor or recipient;
o For purposes of national security and
intelligence (for example, to enable government agencies to conduct special
investigations or to provide protection to certain individuals);
o To military authorities if you are a member
of the armed services, and military authorities determine that disclosure
of such information is necessary;
o To correctional institutions or law enforcement
officials regarding individuals in custody;
o For research purposes in limited
circumstances;
o To coroners, medical examiners, and funeral
directors (for example, to identify a person or cause of death);
o As an incidental disclosure that occurs
during a permitted use or disclosure of PHI;
o As part of a “limited data set” for
research, public health and health care operations, to certain third
parties who have agreed in writing to limit their use and disclosure of the
information in the limited data set.
Other uses and disclosures will be made
only with your written authorization or that of your personal
representative, and you may revoke such authorization as provided by
section 164.508(b)(5) of the Privacy Rule. Any disclosures that were made
when your Authorization was in effect will not be taken back.
Certain
Other Health Information
Please note that not all of your health
information is subject to protection under these rules. In particular, the
use or disclosure of health information that you provide (or that is
provided by someone else at your request) to Formed Fiber as your employer,
and is maintained as part of your employment records, is not subject to
these rules. Your employer may use or disclose such health information for
employment-related purposes, for example to fulfill its legal obligations
under the federal Family and Medical Leave Act or under the Americans With
Disabilities Act, or in connection with providing life insurance or
disability benefits for you (or your beneficiaries). In addition,
information created or received by your employer in connection with
workers’ compensation benefits is not protected under the Privacy Rule.
Your
Health Information Rights
You have the following rights with respect to your PHI. To
exercise any of these rights, you must submit a written request to Privacy
Officer, 125 Allied Road, Auburn, ME 04211, 207-784-1135.
1.
The right to inspect and copy your PHI, as provided by section
164.524 of the Privacy regulations.
2.
The right to request restrictions on certain uses and
disclosures of your PHI, as provided by section 164.522(a) of the Privacy
regulations (although the Health Plan is not required to agree to a
requested restriction).
3.
The right to request confidential communications of your PHI,
if you believe a Health Plan’s usual method of communicating PHI may
endanger you, as provided by section 164.522(b) of the Privacy regulations.
A Health Plan will accommodate your reasonable requests to the extent
feasible.
4.
The right to amend PHI you feel is incorrect, as provided by
section 164.526 of the Privacy regulations. A Health Plan may deny your
request, but must respond to you in either case.
5.
The right to receive an accounting of disclosures a Health
Plan has made of your PHI, as provided by section 164.528 of the Privacy
regulations. The Health Plan is not required to, and will not, account for
disclosures made for treatment, payment or health care operations, national
security, law enforcement, to corrections personnel, pursuant to your
Authorization, or to you. Please note the time period for which you want an
accounting, and the format in which you wish to receive it (e.g., paper or
electronically). Note that we will not account for disclosures made more
than six years prior to your request, nor for disclosures made before HIPAA
became effective for a Health Plan (April 14, 2004). The Health Plan will
provide one accounting of disclosures free of charge once every twelve
months.
6.
The right to file a complaint if you feel your privacy rights
have been violated. For details, see subsequent section of this Notice
entitled “For More Information or To Report a Problem.” Neither the Health
Plan nor the Plan Sponsor will retaliate against you for filing a
grievance.
7. The right to receive a paper copy of this
Notice upon request to the Health Plan, even if you have previously agreed
to receive this Notice electronically.
Health
Plan’s Responsibilities Regarding Your PHI
HIPAA requires a Health Plan to:
- maintain the privacy of your PHI
- provide you with a Notice as to the Plan Sponsor’s
legal duties and privacy practices with respect to information we
collect and maintain about you
- abide by the terms of this Notice
The Health Plan reserves the right to change the terms of this
Notice at any time and to make the revised Notice provisions effective for
all PHI the Health Plan maintains, even PHI obtained prior to the effective
date of the revisions.
If the Health Plan makes a material revision to this Notice,
it will notify you within sixty (60) days after the date the material
change is made by mailing a notice that the Notice has been revised and can
be downloaded from the web site or you can call or write back to request
that a copy of the revised Notice be sent to you.
You can obtain additional copies of this Notice by calling the
Privacy Officer at 207-784-1135. You can also view and print this Notice by
visiting the Plan Sponsor web site at:
http://www.formedfiber.com/employment.html
If you have other medical insurance,
you may receive other privacy notices. The policies and procedures
contained in this Notice are only for the Formed Fiber Health Plans as
described in this Notice.
For
More Information or to Report a Problem
If you have any questions about this Notice, you would like
additional information, or you believe your privacy rights have been
violated, please contact either of the following:
Formed Fiber Technologies,
Inc.
Attn: Health Information Privacy Officer
125 Allied Road
Auburn, ME 04211
Tel: 207-784-1135
OR
In Maine:
Region I, Office for Civil Rights
U.S. Department of Health and Human Services
Government Center
J.F. Kennedy Federal Building, Room 1875
Boston, MA 02203
Tel: 617-565-1340
In South Carolina:
Region IV, Office for Civil Rights
U.S. Department of Health and Human Services
Atlanta Federal Center, Suite 3B70
61 Forsyth Street, SW
Atlanta, GA 30303-8909
Tel: 404-562-7886
In
Ohio:
Region V, Office for Civil Rights
U.S. Department of Health and Human Services
233 N. Michigan Avenue, Suite 240
Chicago, IL 60601
Tel: 312-886-2359
Your benefits will NOT be
affected if you file a complaint.
It is against the law for the Plan Sponsor to take any
retaliatory or other negative action against you if you file a complaint.
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