Use and Disclosure of Health Information The Plan may use your health information, that is, information that constitutes protected health information as defined in the Privacy Rule of the Administrative Simplification provision of the Health Insurance Portability and Accountability Act of 1996 (“HIPPA”), for purposes of making or obtaining payment for your care and conducting health care operations. The Plan has established a policy to guard against unnecessary disclosure for your health information.

The following is a summary of the circumstances under which and purposes for which your health information may be used and disclosed:

To Make or Obtain Payment. The Plan may use or disclose your health information to make payment to or collect payment from third parties, such as other health plans or providers, for the care you receive. For example, the Plan may provide information regarding your coverage or health care treatment to other health plans to coordinate payment of benefits.

To Conduct Health Care Operations. The Plan may use or disclose health information for its own operations to facilitate the administration of the Plan and as necessary to provide coverage and services to all of the Plan’s participants. Health care operations include such activities as:

  • Quality assessment and improvement activities;
  • Activities designed to improve health or reduce health care costs;
  • Case management and care coordination;
  • Contacting health care providers and participants with information about treatment alternatives and other related functions;
  • Underwriting, premium rating or related functions to create, renew or replace health insurance or health benefits;
  • Review and auditing, including compliance reviews, medical reviews, legal services and compliance programs;
  • Business planning and development, including cost management and planning related analyses and formulary development;
  • Business management and general administrative activities of the Plan, including customer service and resolution of internal grievances.

For Treatment Alternatives.The Plan may use and disclose your health information to tell you about or recommend possible treatment options or alternatives that may be of interest to you.

For Distribution of Health-Related Benefits and Services. The Plan may use or disclose your health information to provide you with information on health-related benefits and services that may be of interest to you.

For Disclosure to the Plan Sponsor (Your Employer). The Plan may disclose your health information to the Plan Sponsor for administration functions performed by the Plan Sponsor on behalf of the Plan, such as enrollment and eligibility, and assistance with claim questions. In addition, the Plan may provide summary health information to the Plan Sponsor so the Plan Sponsor may solicit premium bids from health insurers or modify, amend or terminate the Plan.
The Plan also may disclose to the Plan Sponsor information on whether you are participating in the Health Plan.

When Legally Required. The Plan will disclose your health information when it is required to do so by any federal, state or local law:

  • To conduct health oversight activities The Plan may disclose your health information to a health oversight agency for authorized activities, including audits, civil administrative or criminal investigations, inspections, licensure or disciplinary action. The Plan, however, may not disclosure your health information if you are the subject of an investigation and the investigation does not arise out of or is not directly related to your
    receipt of health care or public benefits.
  • In connection with judicial and administrative proceedings. As permitted or required by state law, the Plan may disclose your health information in the course of any judicial or administrative proceeding in response to an order of a court or administrative tribunal as expressly authorized by such order or in response to a subpoena, discovery request or other lawful process, but only when the Plan makes reasonable efforts to either notify you
    about the request or to obtain an order protecting your health information.
  • For law enforcement purposes. As permitted or required by state law, the Plan may disclose your health information to a law enforcement official for certain law enforcement purposes, including, but not limited to, if the Plan has a suspicion that your death was the result of criminal conduct or in an emergency to report a crime.
  • In the event of a serious threat to health or safety. The Plan may, consistent with applicable law and ethical standards of conduct, disclose your health information if the Plan, in good faith, believes that such disclosure is necessary to prevent or lessen a serious and imminent threat to your health or safety or to the health and safety of the public.
  • For specified government functions. In certain circumstances, federal regulations require the Plan to use or disclose your health information to facilitate specified government functions related to the military and veterans, national security and intelligence activities, protective services of the president and others, and correctional institutions and inmates.
  • For Workers’ Compensation. The Plan may release your health information to the extent necessary to comply with laws related to workers’ compensation or similar programs.

Authorization to Use or Disclose Health Information. Other than as stated above, the Plan will not disclose your health information unless it has your written authorization. If you authorize the Plan to use or disclose your health information, you may revoke that authorization in writing at any time.

Your Rights with Respect to your Health Information. You have the following rights regarding your health information that the Plan maintains:

  • Your Right to Request Restrictions You may request restrictions on certain uses and disclosures of your health information. You have the right to request a limit on the Plan’s disclosure of your health information to someone involved in the payment of your care. However, the Plan is not required to agree to your request. If you wish to make a request for restrictions, please contact the Plan’s Privacy Official.
  • Your Right to Receive Confidential Communications. You have the right to request that the Plan communicate with you in a certain way if you feel the disclosure of your health information could endanger you. For example, you may ask that the Plan only communicate with you at a certain telephone number or by email. If you wish to receive confidential communications, please make your request in writing to the Plan’s Privacy Official. The Plan will attempt to honor your reasonable requests for confidential communications.
  • Your Right to Amend Your Health Information. If you believe that your health information records are inaccurate or incomplete, you may request that the Plan amend the records. That request may be made as long as the information is maintained by the Plan. A request for an amendment of records must be made in writing to the Plan’s Privacy Officer. The Plan may deny the request if it does not include a reason to support the amendment. The request also may be denied if your records were not created by the Plan, if the health information you are requesting to amend is not part of the Plan’s records, if the health information you wish to amend falls within an exception to the health information you are permitted to inspect and copy, or if the Plan determines the records containing your health information are accurate and complete.
  • Your Right to an Accounting of Disclosures. You have the right to request a list of certain disclosures of your health information that the Plan is required to keep a record of under the Privacy Rule, such as disclosures for public purposes authorized by law or disclosures that are not in accordance with the Plan’s privacy policies and applicable law. The request must be made in writing to the Plan’s Privacy Official. The request should specify the time period for which you are requesting the information, but may not start earlier than April 14, 2003. Accounting requests may not be made for periods of time going back more than six (6) years. The Plan will provide the first accounting you request during any 12-month period without charge. Subsequent accounting requests may be subject to a reasonable cost-based fee. The Plan will inform you in advance of the fee, if applicable.
  • Your Right to a Paper Copy of this Notice. You have a right to request and receive a paper
    copy of this Notice at any time, even if you have received this Notice previously or agreed to receive the Notice electronically. To obtain a paper copy, please contact the Plan’s Privacy Official.

Duties of the Plan. The Plan is required by law to maintain the privacy of your health information as set
forth in this Notice, and to provide to you this Notice of its duties and privacy practices. The Plan is required to abide by the terms of this Notice, which may be amended from time to time. The Plan reserves the right to change the terms of this Notice and to make the new Notice provisions effective for all health information that it maintains. If the Plan changes its policies and procedures, the Plan will revise the Notice and will provide a copy of the revised Notice to you within 60 days of the change. You have the right to express complaints to the Plan and to the Secretary of the Department of Health and Human Services if you believe that your privacy rights have been violated. For complaints involving this Plan, write to Region II, Office for Civil Rights, U.S. Dept. of Health and Human Services, Jacob Javits Federal Building, 26 Federal Plaza, Suite 3312, New York, New York 10278. Any complaints to the Plan
should be made in writing to the Plan’s Privacy Official. The Plan encourages you to express any concerns you may have regarding the privacy of your information. You will not be retaliated against in any way for filing a complaint.

BY THIS AGREEMENT, the Orange Ulster School District Health Plan, for the account of all participating
School Districts, is hereby adopted as shown.
IN WITNESS WHEREOF, this instrument is executed for the Trustees of the Orange Ulster School
Districts Health Plan on the day and year first below written, for the Plan restatement date of January 1,
By: ____________________________________________
Trustees – Orange Ulster School Districts Health Plan
Title: ____________________________________________
Date: ____________________________________________
Witness: ___________________________________________
Date: ____________________________________________