GUARANTY INCOME LIFE INSURANCE COMPANY
HIPAA NOTICE OF PRIVACY PRACTICES FOR
PERSONAL HEALTH INFORMATION
This Notice of Privacy Practices is effective April 14, 2003
THIS NOTICE DESCRIBES HOW MEDICAL
ABOUT YOU MAY BE USED AND DISCLOSED AND
HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW IT CAREFULLY.
The terms of this Notice of Privacy Practices
Guaranty Income Life Insurance Company
operating as an affiliated covered entity with
exclusive third party administrators
Long-Term Care Group, Inc.
Dental Management Corporation, Inc.
You have received this Health Information Privacy Notice because you have applied for or have long-term care or dental insurance coverage with Guaranty Income Life Insurance Company ("GILICO").
OUR PLEDGE REGARDING MEDICAL INFORMATION
We understand that medical information about you and your health is personal. We are committed to protecting personal health information about you. This notice will tell you about the ways in which we may use and disclose medical information about you. We also describe your rights and certain obligations we have regarding the use and disclosure of personal health information.
We are required to provide you with this Notice in accordance with federal health privacy regulations that were issued as a result of the Health Insurance Portability and Accountability Act (HIPAA).
We are required by law to:
We reserve the right to change the terms of this Notice of Privacy Practices as necessary and to make the new Notice effective for all personal health information maintained by us. Copies of revised notices will be mailed to all health plan members then covered by the plan.
As a health plan member you have the right to obtain a paper copy of this Notice of Privacy Practices, even if you have requested such copy by e-mail or other electronic means. Copies may be obtained by mailing a written request to the Privacy Official identified at the end of this notice.
USES AND DISCLOSURES OF YOUR MEDICAL INFORMATION
Your Authorization. Except as outlined below, we will not use or disclose your personal 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.
Uses and Disclosures for Payment. We will make uses and disclosures of your personal 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 benefits 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.
Uses and Disclosures for Health Care Operations. We will use and disclose your personal health information as necessary, and as permitted by law, for our health care operations which include credentialing health care providers, peer review, business management, accreditation and licensing, utilization review and management, quality improvement and assurance, enrollment, underwriting, reinsurance, compliance, auditing, rating, and other functions related to your health benefits plan.
Family and Friends Involved In Your Care. With your approval, we may from time to time disclose your personal health information to designated family, friends, and others who are involved in your care or in payment for your care in order to facilitate that persons involvement in caring for you or paying 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 personal health information with such individuals without your approval. If you have designated a person to receive information regarding payment of the premium on your policy, we will inform that person when your premium has not been paid. We may also disclose limited personal health information to a public or private entity that is authorized to assist in disaster relief efforts in order for that entity to locate a family member or other persons that may be involved in some aspect of caring for you.
Business Associates. Certain aspects and components of our services may be performed through contracts with outside persons or organizations, such as auditing, accreditation, actuarial services, legal services and third party administration for underwriting, claims administration and care management, etc. At times it may be necessary for us to provide certain of your personal 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 information.
Communications With You. We may communicate with you regarding your claims, premiums, or other things connected with your health plan. You have the right to request and we will accommodate reasonable requests by you to receive communications regarding your personal health information from us by alternative means or at alternative locations. For instance, if you wish messages to not be left on voice mail or sent to a particular address, we will accommodate reasonable requests. You may request such confidential communication in writing and may send your request to the Privacy Official identified at the end of this notice.
Other Health-Related Products or Services. We may, from time to time, use your personal health information to determine whether you might be interested in or benefit from treatment alternatives or other health-related programs, products or services which may be available to you as a member of the health plan. For example, we may use your personal health information to identify whether you have a particular illness, and contact you to advise you that a disease management program to help you manage your illness better is available to you as a health plan member. We will not use your information to communicate with you about products or services which are not health-related without your written permission. You also have the right to request that we not send you any future marketing materials and we will use our best efforts to honor such request. You may make the request by sending your name and address to the Privacy Official identified at the end of this notice with your request to be removed from our marketing mailing lists.
Information Received Pre-enrollment. We may request and receive from you and your health care providers personal health information prior to the issuance of a policy to you. We will use this information to determine whether you are eligible for a policy and to determine your rates. We will protect the confidentiality of that information in the same manner as all other personal health information we maintain and, if the policy is not issued, we will not use or disclose the information that we obtained about you for any other purpose.
Research. In limited circumstances, we may use and disclose your personal health information for research purposes. For example, a research organization may wish to compare outcomes of patients by payer source and will need to review a series of records that we hold. In all cases where your specific authorization has not been obtained, your privacy will be protected by strict confidentiality requirements applied by an Institutional Review Board or privacy board which oversees the research or by representations of the researchers that limit their use and disclosure of member information.
Other Uses and Disclosures. We are permitted or required by law to make certain other uses and disclosures of your personal health information without your authorization.
RIGHTS THAT YOU HAVE
Access to Your Personal Health Information. You have the right to copy and/or inspect much of the personal health information that we retain on your behalf. All requests for access must be made in writing and signed by you or your legal representative. We may charge a minimum fee to cover our costs for supplies, labor and postage. You may request access to your personal health information by contacting our Customer Service Department at (800) 535-8110.
Amendments to Your Personal Health Information. You have the right to request in writing that personal 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 legal 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 request amendments to your personal health information by contacting our Customer Service Department at (800) 535-8110.
Accounting for Disclosures of Your Personal Health Information. You have the right to receive an accounting of certain disclosures made by us of your personal health information after April 14, 2003. You may request an accounting of the types of disclosures as described above under the title "Other Uses and Disclosures" except for disclosures made for national security or intelligence purposes. Requests must be made in writing and signed by you or your representative. You may request an accounting for disclosure of your personal health information by contacting our Customer Service Department at (800) 535-8110. The first accounting in any 12-month period is free. You may be charged a fee of $20.00 for each subsequent accounting you request within the same 12-month period.
Restrictions on Use and Disclosure of Your Personal Health Information. You have the right to request restrictions on certain of our uses and disclosures of your personal health information for treatment, payment, or health care operations by notifying us of your request for a restriction in writing mailed to Guaranty Income Life Insurance Company, P. O. Box 2231, Baton Rouge, Louisiana 70821. Your request must describe in detail the restriction you are requesting. We are not required to agree to your restriction request but will attempt to accommodate reasonable requests when appropriate 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. Also, should you wish to terminate a request that has been accommodated, such termination request must also be in writing and sent to the same address listed above.
Complaints. If you believe your privacy rights have been violated, you can file a written complaint with Privacy Official, Guaranty Income Life Insurance Company, P.O. Box 2231, Baton Rouge, Louisiana 70821. 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.
You will not be penalized for filing a complaint.
FOR FURTHER INFORMATION
If you have questions or need further assistance regarding this Notice or GILICOs privacy practices, you may contact the Privacy Official for our organization:
Guaranty Income Life Insurance Company
ATTN: Privacy Official
P.O. Box 2231
Baton Rouge, Louisiana 70821