PATIENT NOTICE OF PRIVACY PRACTICES
Effective April 14, 2003; Revised September 23, 2013
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
At *TakeCare , the protection of our member’s privacy and confidentiality of medical information has always been a top priority. We recognize that you depend upon us to safeguard your personal information and uphold your privacy rights. This document—which is based on **state and federal law, as well as our own company code of ethics—offers a declaration of our commitment to preserving patient confidentiality and privacy.
* “TakeCare ” refers to TakeCare Insurance Company, Inc., TakeCare Insurance Brokers, Inc. and TakeCare Insurance Risk Management Services, Inc. This notice is applicable to all TakeCare-related companies.
* * “State” is defined as Guam, Commonwealth of the Northern Mariana Islands or the Republic of Palau.
OUR PRIVACY PRACTICES
This notice describes TakeCare ’s privacy practices for our current and former patients. It explains how we use information about you and when we may share this information with others. It also informs you about your rights with respect to your health information and how you may exercise these rights. It is your right to receive a copy of this notice. We are required by law to maintain the privacy of your health information and to make a copy of this notice available to you so that you are aware of how we maintain the privacy of your health information. We will inform you promptly if a breach occurs that may have compromised the privacy or security of your information. You will be asked to sign an acknowledgement of receipt for this notice. If you choose to not sign an acknowledgement of receipt for this notice, it will be noted in your record and we will still continue to provide you with treatment and use and disclose your health information, when necessary for treatment, payment, and health care operations.
HEALTH CARE INFORMATION MAINTAINED AT TAKECARE
When we refer to “information” or “health information” in this notice, we mean information about you, including demographic information that may identify you and relates to your past, present or future physical or mental health and related health care services.
Health information may be transmitted or shared in any form or medium (oral, written, or electronic). The information we receive may vary by product; therefore, the examples that follow may not apply to all patients, but are designed to show the general categories of information that may be received and maintained by TakeCare :
- Information provided by you on applications, forms, surveys and our Web sites, such as your name, address and date of birth.
- Information from physicians, hospitals or other health care providers, clinics, medical groups or health care service plans.
- Information provided by your employer, benefits plan sponsor or association, regarding any group product that you may have.
- Information about your transactions and experiences with our affiliates, others, and us, such as: products or services purchased, account balances, payment history, claims history, policy coverage and premium.
- Information from consumer or medical reporting agencies or other third parties, including medical and demographic information.
HOW WE MAY USE OR SHARE YOUR INFORMATION
The following categories describe how we may use and share your information. For each category we will provide examples that help illustrate each type of use or disclosure. Not every use or disclosure in a category will be listed. However, the ways in which we are permitted to use and share information will fall into one of these categories.
We may share health information with your doctors, other health care providers, hospitals, health plans, health care facilities, and health care vendors to help them provide health care for you. For example, if you are hospitalized, we may allow the appropriate hospital staff access to your medical records. We may also allow another physician who becomes involved in your health care (at the request of your physician) treatment or diagnosis access to your medical records. We may also use or share your health information with others to help coordinate and manage your health care and any related services. For example, we may talk to your doctor to recommend a disease management or wellness program that can help improve your health or talk to a pharmacist who may need health information on drugs you have been prescribed to identify potential interactions. In the event of an emergency, we will use and disclose your health information to provide treatment to you as required.
We may use your health information when obtaining payment for your health care services. For example, TakeCare will share your health information with your insurance company to obtain payment for TakeCare Home Health services.
For Health Care Operations
We may use or share certain health information for necessary health care operations. Examples of health care operations include the following:
- Performing quality assessment and improvement activities;
- Evaluating provider and staff performance reviews;
- Conducting or arranging for medical review to determine medical necessity, level of care or justification of services;
- Performing auditing functions;
- Resolving internal grievances, such as addressing problems or complaints about your access to care or satisfaction with services;
- Making benefit determinations and providing customer service; and
- Other uses specifically authorized by law.
We may also share your health information with other individuals or entities—also known as business associates—that help us conduct our health care operations (for example: interpreter services, transcription services, or dental software vendor for the TakeCare Dental Center). However, we will not share your health information with these business associates unless they agree in writing to protect the privacy of that health information.
To Make Certain Communications to You
We may use or share your health information to inform you about alternative medical treatments and programs or about health-related products and services that may be of value to you.
We may use and disclose health information to contact you as a reminder that you have an appointment for health care with TakeCare . For example, we may remind you by telephone or by mail of your doctor’s appointment at TakeCare Dental Center or at TakeCare Health Center (Saipan).
Information Not Personally Identifiable
We may use or share your health information when it has been “de-identified.” Information is considered to be de-identified when it does not personally identify you. We may also use a “limited data set” that does not contain any information that can directly identify you. This limited data set may only be used for the purposes of research, public health matters or health care operations. For example, a limited data set may include your city, county and zip code, but not your name or street address.
Individuals Involved in Your Health Care
We may disclose your health information to your family member, close friend or any other person you identify as directly being involved in your health care or pays for your health care if you verbally agree or if given the opportunity you do not express an objection or if it can be inferred from the circumstances based on TakeCare ’s professional judgment that you would not object. For example, we may allow your family member, close friend, or any other person you identify directly involved in your health care, to pick up prescriptions, medical supplies, or X-rays from the TakeCare Health Center (Guam) or eyeglasses from the TakeCare Vision Center or other similar forms of health care products or health care information.
SPECIAL CIRCUMSTANCES AND STATE FEDERAL LAWS
Special situations, along with certain state and federal laws, may require us to release your health information. For example, we may be obligated to release your health information for the following reasons:
- To comply with state and federal laws that requires us to release your health information to others.
- To report information to state and federal agencies that regulate our business, such as the U.S. Department of Health and Human Services and your state’s regulatory agencies.
- To assist with public health activities; for example, to collect or receive information for preventing or controlling disease, injury, or disabilities; for reporting births and deaths; for reporting a patient who is exposed to or is at risk for contracting or spreading a disease or condition.
- To report information to the Food and Drug Administration for the purpose of investigating or trackinga prescription drug; reporting reactions or problems to medications; reporting adverse events to food or dietary supplements, product defects, problems and biologic product deviations; track or enable product recalls, repairs or replacements; conducting required product performance surveillance.
- To report information to public health agencies if we believe there is a serious threat to your health and safety or that of the public or another person; this includes disaster relief efforts.
- To report certain activities to health oversight agencies; for example, we may report activities involving audits, inspections, licensure and peer review activities.
- To assist court or administrative agencies; for example, we may provide information pursuant to a court order, search warrant or subpoena.
- To support law enforcement activities; for example, we may provide information to law enforcement agents for the purpose of identifying or locating a fugitive, material witness or missing person; responses to legal proceedings; circumstances pertaining to victim(s) of a crime; deaths suspected from criminal conduct; crimes or medical emergencies occurring on or not on TakeCare premises believed to be a result of criminal conduct.
- To correctional institutions or law enforcement officials if you are an inmate or under the custody of a law enforcement official.
- To report information to government authority(s) regarding adult or child abuse, neglect or domestic violence.
- To share information with a coroner or medical examiner as authorized by law (we may also share information with funeral directors, as necessary).
- To use or share information for procurement, banking or transplantation of organs, eyes or tissues.
- To report information regarding job-related injuries as required by your state worker compensation laws.
- To share information related to specialized government functions, such as military and veteran activities, national security and intelligence activities and protective services for the President and others.
- To researchers when their research has been approved by an institutional review board that has approved the research proposal and established protocols to ensure the privacy of your health information.
- To a family member or friend under any of the following circumstances: (1) if you provide a verbal agreement to allow such a disclosure; (2) if you are given an opportunity to object to such a disclosure and you do not raise an objection; or (3) if it can be inferred from the circumstances based on TakeCare ’s professional judgment, that you would not object.
- To disclose proof of immunization to a school where State or other law requires the school to have such information prior to admitting the student when an agreement, which may be oral, from a parent, guardian or other person acting in loco parentis for the individual, or from the individual himself or herself, if the individual is an adult or emancipated minor is provided.
WRITTEN PERMISSION TO USE OR SHARE YOUR INFORMATION
We will never share your information for marketing purposes or sale your information unless you give us written permission to do so.
For any other activity or purpose not listed above we must obtain your written permission—known as an authorization—prior to using or sharing your health information. If you provide a written authorization and you decide to change your mind, you may revoke your authorization in writing at any time. Once an authorization has been revoked, we will no longer use or share the information as outlined in the authorization form; however, you should be aware that we may not be able to retract a use or disclosure that was previously made based on a valid authorization
OTHER RESTRICTIONS REGARDING USE AND DISCLOSURE OF YOUR INFORMATION
Depending on where you reside, there may be additional laws related to the use and disclosure of information related to HIV status, communicable diseases, reproductive health, genetic test results, substance abuse, mental health and mental retardation.
YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION
The following are your rights with respect to your health information. If you would like to exercise the following rights, please call TakeCare Health Center (Guam) Customer Service at (671) 646-5825 or TakeCare Health Center (Saipan) Customer Service at (670) 235-0998.
You have the right to ask us to restrict how we use or share your health information for treatment, payment or health care operations. You also have the right to ask us to restrict information that we have been asked to give to family members or to others who are involved in your health care or payment for your health care. Please note that while we will try to honor your requests, we are not required by law to agree to the type of restrictions described above.
You have the right to request confidential communications of information.
For example, if you believe that sending your information to your current mailing address would put your safety at risk (e.g., in situations involving domestic disputes or violence), you may ask us to send the information by alternative means (e.g., such as by fax or to an alternate address). We will accommodate reasonable requests for confidential communication of your health information.
You have the right to inspect and obtain a copy of the information we maintain about you in a designated record set. A designated record set refers to patient medical records and billing records. Patient medical records include records in any form or medium maintained by or in the custody or control of a health care provider relating to health history, diagnosis, or condition of a patient, or relating to treatment provided or proposed to be provided to the patient. Billing records include claims, account statements, and account summaries maintained by or for TakeCare. This right does not obligate us to grant you access to certain types of health information. Please note that under most circumstances we will not provide you with copies of the following information:
- Psychotherapy notes.
- Information compiled in reasonable anticipation of, or for use in, a civil criminal administrative action or proceeding.
- Information subject to certain federal laws governing biological products and clinical laboratories.
- Medical information compiled and used for quality assurance or peer review purposes.
If you request a copy of your designated record set, a fee for the costs of copying, mailing or other associated supplies and including administrative labor, may be charged. Additionally, under certain circumstances we may deny your request to inspect or obtain a copy of your health information. If we deny your request, we will notify you in writing and may provide you the option to have the denial reviewed. If you would like to request access to review or copy your patient medical records please let us know by calling TakeCare (Guam) Customer Service at (671) 646-5825 or TakeCare Health Center (Saipan) Customer Service at (670) 235-0998 during regular business hours or contact the health care provider who created and/or maintains the record(s).
You have the right to ask us to make changes to the health information that we maintain about you in your designated record set.
These changes are referred to as amendments. We may require that your request be in writing and that you provide a reason for your request. If we make the amendment, we will notify you that it was made. If we deny your request to amend, we will notify you in writing of the reason for denial. This written notification will explain your right to file a written statement of disagreement. In return, we have a right to rebut your statement. Furthermore, you have the right to request that your initial written request, our written denial and your statement of disagreement be included with your health information for any future disclosures.
You have the right to receive an accounting of certain disclosures of your health information made by us during the six years prior to your request.
We may require that your request for an accounting be in writing. Your first accounting is free. Subsequently, you are allowed one free accounting upon request every 12 months. If you request an additional accounting within 12 months of receiving your free accounting, we may charge you a fee. We will inform you in advance of the fee and provide you with an opportunity to withdraw or modify your request.
Please note that, under most circumstances, we are not required to provide you with an accounting of disclosures of the following information:
- Any information collected prior to April 14, 2003.
- Information shared for treatment, payment or health care operations.
- Information already disclosed to you.
- Information shared as part of an authorization request.
- Information that is incidental to a use or disclosure that is otherwise permitted.
- Information provided for use in a facility directory.
- Information that was provided to persons involved in your care or for other notification purposes.
- Information shared for national security or intelligence purposes.
- Information that was shared or used as part of a limited data set for research, public health or health care operation purposes.
- Information disclosed to correctional institutions, law enforcement officials or health oversight agencies.
You have the right to request for us not to disclose information to health plans about care you have received that you have paid out-of-pocket for.