HIPPA Notice

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.

This is your Health Information Privacy Notice from Combined Life Insurance Company of New York (referred to as We or Us). This notice is effective April 14, 2003.This notice is solely for your information. You do not need to take any action.

This notice provides you with information about the way in which We protect Personal Health Information (“PHI”) that We have about you. PHI includes individually identifiable information which relates to your past, present or future health, treatment or payment for health care services. This notice also explains your rights with respect to PHI.

The Health Insurance Portability and Accountability Act (“HIPAA”) requires Us to: Keep Personal Health Information PHI about you private; provide you this notice of our legal duties and privacy notices with respect to your PHI; and follow the terms of the notice that are currently in effect.
Use and Disclosure of PHI
We obtain PHI in the course of providing and/or administering health insurance benefits for you. In administering your benefits, We may use and/or disclose Personal Health Information PHI about you and your dependents. The following are some examples, however, not every use or disclosure in a category will be listed:

• For Health Care Payment Purposes: For example, We may use and disclose Personal Health Information PHI to administer and process payment of benefits under your insurance coverage, determine eligibility for coverage, claims or billing information, conduct utilization reviews, or to another entity or health care provider for its payment purposes.

• For Health Care Operations Purposes: For example, We may use and disclose Personal Health Information PHI for underwriting and rating of the plan, audits of your claims, quality of care reviews, investigation of fraud, performance measurements, care coordination, investigate and respond to complaints or appeals, provider treatment, review and provision of services.
• For Treatment Purposes. For example, We may use and disclose information PHI to health care providers to assist in their treatment of you. We do not provide health care treatment to you directly.
• For Health Services. For example, We may use your medical information to contact you to give you information about treatment alternatives or other health related benefits and services that may be of interest to you as part of large case management or other insurance related services.
• For Data Aggregation Purposes. For example, We may combine PHI about many insured participant to make plan benefit decisions, and the appropriate premium rate to charge.
• To You About Dependents. For example, We may use and disclose PHI about your dependents for any purpose identified herein. We may provide an explanation of benefits for you or any of your dependents to you.
• To Business Associates. For example, We may disclose PHI to administrators who are contracted with Us who may use the PHI to administer health insurance benefits on our behalf and such administrators may further disclose PHI to their contractors or vendors as necessary for the administration of health insurance benefits.

If your state has adopted a more stringent standard regarding any of the above uses or disclosures of your PHI, those standards will be applied.
Additional Uses or Disclosures. We may also disclose PHI about you for the following purposes:

• To comply with legal proceedings, such as a court or administrative order, subpoena or discovery requests.
• To law enforcement officials for limited law enforcement purposes.
• To a family member, friend or other person, for the purpose of helping you with your health care or with payment for your health care, if you are in a situation such as a medical emergency and you cannot give your agreement to the Plan to do this.
• To your personal representatives appointed by you or designated by applicable law.
• For research purposes in limited circumstances.
• To a coroner, medical examiner, or funeral director about a deceased person.
• To an organ procurement organization in limited circumstances.
• To avert a serious threat to your health or safety or the health or safety of others.
• To a governmental agency authorized to oversee the health care system or government programs.
• To the Department of Health and Human Services for the investigation of compliance with HIPAA or to fulfill another lawful request.
• To federal officials for lawful intelligence, counterintelligence, national security purposes and to protect the president.
• To public health authorities for public health purposes.
• To appropriate military authorities, if you are a member of the armed forces.
• In accordance with a valid authorization signed by you.

Your Rights Regarding PHI That We Maintain About You
You have various rights as a consumer under HIPAA concerning your PHI. You may exercise any of these rights by writing to Us in care of The Allen J. Flood, 2 Madison Avenue, Larchmont, NY, 10538, Attention: HIPAA Privacy Office:
• You have the right to inspect and copy your PHI that We maintain. If you request a copy of the information, We may charge a fee for the costs of copying, mailing or other supplies associated with your request.
• You have the right to ask Us to amend the PHI that is contained in a “designated record set”, e.g., information used to make enrollment, eligibility, payment, claims adjudication and other decisions. You have the right to request an amendment for as long as we maintain the PHI. Requests must be made in writing and include the reason for the request. We may deny the request if the PHI is accurate and complete or if we did not create the PHI.
• You have the right to request a list of our disclosures of the PHI. Your request must state a time period, may not include dates before April 14, 2003 and may not exceed a period of six years prior to the date of your request. If you request more than one list in a year, We may charge you the cost of providing the list. We will notify you of the cost and you may withdraw or modify your request before any costs are incurred. Any list of disclosures provided by Us will not include disclosures made for payment, treatment or healthcare operations; made to you or persons involved in your care; incidental disclosures, authorized disclosures, for national security or intelligence purposes or to correctional institutions.
• You have the right to request to restrict the way We use or disclose PHI regarding treatment, payment or health care operations. You also have the right to request to restrict the PHI We disclose about you to someone who is involved in your care or the payment for your care. We are not required to agree to your request. If We do agree, We will comply with your request unless the information is needed to provide you emergency treatment. Your request must be in writing and state (1) what information you want to restrict; (2) whether you want to restrict our use, disclosure or both; and (3) to whom you want the restrictions to apply.
• Uses and disclosures of your PHI, other than those listed above, require prior written authorization from you. You may revoke that authorization at any time by writing to Us at the address at the end of this notice.
• You have the right to request that We communicate personal information to you in a certain way or at a certain location. Your request must specify how or where you wish to be contacted. We will comply with reasonable requests.
• You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice upon request. You may request a paper copy of this notice any of the above described by calling Us at 1-800-951-6206, select HIPAA or submitting the request to the Combined Life Insurance Company of New York, 5050 Broadway, Chicago, IL 60640 Attn: HIPAA Privacy Office.

Complaints

If you believe your privacy rights have been violated, you may file a complaint with Us. When filing a complaint, include your name, address and telephone number and We will respond. All complaints must be submitted in writing to Combined Life Insurance Company of New York, 5050 Broadway, Chicago, IL 60640 Attn: HIPAA Privacy Office. You may also contact the Secretary of the Department of Health and Human Services. You will not be retaliated against for filing a complaint.
Changes To This Notice
We reserve the right to modify this Privacy Notice and our privacy policies at any time. If We make any modifications, the new terms and policies will apply to all PHI Personal Information before and after the effective date of the modifications that We maintain. If We make material changes, We will send a new notice to the insured/subscribers.
If you have any questions regarding this notice, please call 1-800-951-6206, select HIPAA or send your written questions to the address at the end of this notice. Please include your name, the name of your insurance plan, your policy/ID number or copy of ID card, your address and telephone number and We will respond.
All questions and requests regarding your rights under this Notice should be sent to:

Combined Life Insurance Company of New York
C/o The Allen J. Flood Companies, Inc.
2 Madison Avenue
Larchmont, NY 10538
Attention: HIPAA Privacy Office

If you would like the Student Health Center to assist in future claim matters please complete the “Release of Information Form” and return it signed to the Student Health Center.