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NOTICE TO INDIVIDUAL OF
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.
About Your Medical Information
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires
group health plans to notify you about its policies and practices to protect
the confidentiality of your health information. This section is intended
as an overview of those policies and practices as required by federal law.
These policies and practices are effective beginning April 14, 2003.
The plan needs to create, receive, and maintain records that contain health
information about you to administer the plan and provide you with health care
benefits. This section tells you the ways the plan may use and disclose health
information about you, describes your rights, and the obligations the plan
has regarding the use and disclosure of your health information. It does not
address the health information policies or practices of your health care providers.
Lake Superior State University’s Pledge Regarding Health Information
that identifies you and relates to a physical or mental health condition or
the payment of your health care expenses. This individually identifiable health
information is known as “protected health information’ (PHI). Your
PHI will not be used or disclosed without a written authorization from you,
except as described in this notice or as otherwise permitted by federal and
state health information privacy laws.
Privacy Obligations of the Plan
The plan is required by law to:
* Make sure that health information that identifies you is kept private;
* Give you this notice of the plan’s legal duties and privacy practices
with respect to health information about you; and
* Follow the terms of the notice that is currently in effect.
How the Plan May Use and Disclose Health Information About You
The following are the different ways the plan may use and disclose your PHI:
* For treatment. The plan may disclose your PHI to a health care provider who
renders treatment on your behalf. For example, if you are unable to provide
your medical history as the result of an accident, the plan may advise an
emergency room physician about the types of prescription drugs you currently
* For Payment. The plan may use and disclose your PHI so claims for health
care treatment may be paid. For example, the plan may receive and maintain
information about surgery you received so that the plan can process the hospital’s
claim for reimbursement of your surgical expenses.
* For Health Care Operations. The plan may use and disclose your PHI to enable
it to operate or operate more efficiently or make certain all of the plan’s
participants receive their health benefits. For example, the plan may use your
PHI for case management or to perform population-based studies designed to
reduce health care costs. In addition, the plan may use or disclose your PHI
to conduct compliance reviews, audits, actuarial studies, and/or for fraud
and abuse detection. The plan may also combine health information about many
plan participants and disclose it to Lake Superior State University in summary
fashion so it can decide what coverages the plan should provide. The plan may
remove information that identifies you from health information disclosed to
Lake Superior State University so it may be used without LSSU learning who
the specific participants are.
* To Lake Superior State University. The plan may disclose your PHI to designated
Lake Superior State University personnel so they can carry out their plan-related
administrative functions, including the uses and disclosures described in this
notice. Such disclosures will be made only to the plan administrator and/or
the members of the University’s Human Resources Department. These individuals
will protect the privacy of your health information and ensure it is used only
as described here or as permitted by law. Unless authorized by you in writing,
your health information:
* may not be disclosed by the plan to any other University employee or department;
* will not be used by LSSU for any employment-related actions and decisions,
or in connection with any other employee benefit plan sponsored by the University.
* To a Business Associate. Certain services are provided to the plan by third
party administrators and other entities known as “business associates”.
For example, the plan may input information about your health care treatment
into an electronic claims processing system maintained by the plan’s
business associate so your claim may be paid. In so doing, the plan will disclose
your PHI to its business associate so it can perform its claims payment function.
However, the plan will require its business associates, through contract, to
appropriately safeguard your health information.
* Treatment Alternatives. The plan may use and disclose your PHI to tell you
about possible treatment options or alternatives that may be of interest to
* Health-Related Benefits and Services. The plan may use and disclose your
PHI to tell you about health-related benefits or services that may be of interest
* Individual Involved in Your Care or Payment of Your Care. The plan may disclose
PHIto a close friend or family member involved in or who helps pay for your
health care. The plan may also advise a family member or close friend about
your condition, your location (for example, that you are in a hospital) or
* As Required By Law. The plan will disclose your PHI when required to do
so by federal, state or local law, including those that require the reporting
of certain types of wounds or physical injuries.
Special Use and Disclosure Situations
The plan may also use or disclose your PHI under the following circumstances:
* Lawsuits and Disputes. If you become involved in a lawsuit or other legal
action, the plan may disclose your PHI in response to a court or administrative
order, a subpoena, warrant, discovery request, or other lawful due process.
* Law Enforcement. The plan may release your PHI if asked to do so by law
enforcement official. For example, they may use this information to identify
or locate a suspect, material witness, or missing person or to report a crime,
the crime’s location or victims, or the identity, description or location
of the person who committed the crime.
* Worker’s Compensation. The plan may disclose your PHI to the extent
authorized by and to the extent necessary to comply with worker’s compensation
laws or other similar programs.
* Military and Veterans. If you are or become a member of the U.S. armed forces,
the plan may release medical information about you as deemed necessary by military
* To Avert Serious Threat to Health or Safety. The plan may use and disclose
your PHI when necessary to prevent a serious threat to your health and safety,
or the health and safety of the public or another person.
* Public Health Risks. The plan may disclose health information about you
for public health activities. These activities include preventing or controlling
disease, injury or disability; reporting births and deaths; reporting child
abuse or neglect; reporting reactions to medication or problems with medical
products; or notifying people of recalls of products they have been using.
* Health Oversight Activities. The plan may disclose your PHI to a health
oversight agency for audits, investigations, inspections, and licensure necessary
for the government to monitor the health care system and government programs.
* Research. Under certain circumstances, the plan may use and disclose your
PHI for medical research purposes.
* National Security, Intelligence Activities, and Protective Services. The
plan may release your PHI to authorized federal officials for intelligence,
counterintelligence, and other national security activities authorized by law.
It can also be released to enable federal officials to provide protection to
the members of the U.S. government, foreign heads of state, or to conduct special
* Organ and Tissue Donation. If you are an organ donor, the plan may release
medical information to organizations that handle organ procurement or organ,
eye or tissue transplantation or to an organ donation bank to facilitate organ
or tissue donation and transplantation.
* Coroners, Medical Examiners, and Funerals Directors. The plan may release
your PHI to a coroner or medical examiner. This may be necessary, for example,
to identify a deceased person or to determine the cause of death. The plan
may also release your PHI to a funeraldirector, as necessary, to carry out
Your Rights Regarding Health Information About You
Your rights regarding the health information the plan maintains about you are
* Right to Inspect and Copy. You have the right to inspect and copy your PHI.
This includes information about your plan eligibility, claim and appeal records,
and billing records, but does not include psychotherapy notes.
To inspect and copy health information maintained by the plan, submit your
request in writing to the plan administrator. The plan may charge a fee for
the cost of copying and/or mailing your request. In limited circumstances,
the plan may deny your request to inspect and copy your PHI. Generally, if
you are denied access to health information, you may request a review of the
* Right to Amend. If you feel that health information the plan has about you
is incorrect or incomplete, you may ask the plan to amend it. You have the
right to request an amendment for as long as the information is kept by or
for the plan.
To request and amendment, send a detailed request in writing to the plan administrator.
You must provide reasons to support your request. The plan may deny your request
if you ask the plan to amend health information that was not created by the
plan, not part of the health information kept by the plan, or not information
that you would be permitted to inspect and copy.
* Right to An Accounting of Disclosures. You have the right to request and “accounting
of disclosures.” This is a list of disclosures of your PHI that the plan
has made to others, except for those necessary to carry out health care treatment,
payment or operations; disclosures made to you; or in certain other situations.
To request an accounting of disclosures, submit your request in writing to
the plan administrator. Your request must state a time period, which may not
be longer than six years prior to the date the accounting was requested.
* Right to Request Restrictions. You have the right to request a restriction
on your health information the plan uses or discloses for treatment, payment
or health care operations. You also have the right to request a limit on the
health 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 the plan not use or disclose information about
a surgery you had to a family member.
Make your request for restrictions in writing to the plan administrator. You
must state what health information you want to limit, to who you want the limits
to apply, and how you want to limit the plan’s use and disclosure.
NOTE: The plan is not required to agree to your request.
* Right to Request Confidential Communications. You have the right to request
that the plan communicate with you about health matters in a certain way or
at a certain location. For example, you can ask that the plan send you explanation
of benefits (EOB) forms about your benefit claims to a specified address, or
to communicate with you at a certain telephone number, or by e-mail.
To request confidential communications, make your request in writing to the
plan administrator. The plan will make attempt to 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 have the right to a paper copy of
this notice. You may write to the plan administrator to request a written copy
of this notice at any time.
Changes to This Notice
The plan reserves the right to change this notice at any time and to make the
amended notice effective for health information the plan already has about
you, as well as any information the plan receives in the future. If the notice
is revised, we will provide you with a copy. The plan will post a copy of
the current notice on the Human Resources web page at http://www.lssu.edu/human_resources.
If you believe your privacy rights under this policy have been violated, you
may file a written complaint with the plan administrator at the address listed
below. Alternatively, you may complain to the Secretary of the U.S. Department
of Health and Human Services, generally, within 180 days of when the act
or omission complained of occurred.
NOTE: You will not be penalized or retaliated against for filing a complaint.
Other Uses and Disclosures of Health Information
Other uses and disclosures of health information not covered by this notice
or by the laws that apply to the plan will be made only with your written
authorization. If you authorize the plan to use or disclose your PHI, you
may revoke the authorization in writing at any time. If you revoke your authorization,
the plan will no longer use or disclosure your PHI for the reasons covered
by your written authorization. However, the plan will not reverse any uses
or disclosures already made in reliance on your prior authorization.
If you have any questions about this notice, please contact:
Director of Human Resources
LSSU Employee Benefit Plan
650 W. Easterday Avenue
Sault Ste. Marie, MI 49783
Notice Effective Date: April 1, 2003