The only Protected Health Information (PHI) that
Social Security Number, your name, your birth date and sometimes your address and telephone number.
We ONLY use this Protected Health Information to maintain your eligibility records with the carrier.
We do not disclose this information to anyone else.
No Protected Health Information is on or available on our web site.
CONFIDENTIALITY OF YOUR HEALTH INFORMATION
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 notice is required by law to inform you of how Wolfpack Insurance Services and its affiliates ("Wolfpack Insurance Services") protect the confidentiality of your health care information in our possession. Protected Health Information (PHI) is defined as individually identifiable information regarding a patient's health care history, mental or physical condition or treatment. Some examples of PHI include your name, address, telephone and/or fax number, electronic mail address, social security number or other identification number, date of birth, date of treatment, treatment records, x-rays, enrollment and claims records. Wolfpack Insurance Services receives, uses and discloses your PHI to administer your benefit plan or as permitted or required by law. Any other disclosure of your PHI without your authorization is prohibited.
We follow the privacy practices described in this notice and federal and state privacy requirements that apply to our administration of your benefits. Wolfpack Insurance Services reserves the right to change our privacy practice effective for all PHI maintained. We will update this notice if there are material changes and redistribute it to you within 60 days of the change to our practices. We will also promptly post a revised notice on our website. A copy may be requested anytime by contacting the address or phone number at the end of this notice. You should receive a copy of this notice at the time of enrollment in a Wolfpack Insurance Services program and will be informed on how to obtain a copy at least every three years.
PERMITTED USES AND DISCLOSURES OF YOUR PHI
Uses and disclosures of your PHI for treatment, payment or health care operations
Your explicit authorization is not required to disclose information about yourself for purposes of health care treatment, payment of claims, billing of premiums, and other health care operations. If your benefit plan is sponsored by your employer or another party, we may provide PHI to your employer or plan sponsor to administer your benefits. As permitted by law, we may disclose PHI to third-party affiliates that perform services for Wolfpack Insurance Services to administer your benefits, and who have signed a contract agreeing to protect the confidentiality of your PHI, and have implemented privacy policies and procedures that comply with applicable federal and state law.
Some examples of disclosure and use for treatment, payment or operations include: processing your claims, collecting enrollment information and premiums, reviewing the quality of health care you receive, providing customer service, resolving your grievances, and sharing payment information with other insurers. Some other examples are:
· Uses and/or disclosures of PHI in facilitating treatment. For example, Wolfpack Insurance Services may use or disclose your PHI to Delta Dental and/or VSP to update your eligibility.
· Uses and/or disclosures of PHI for payment. For example, Wolfpack Insurance Services may use and disclose your PHI to bill you or your plan sponsor.
Other permitted uses and disclosures without an authorization
We are permitted to disclose your PHI upon your request, or to your authorized personal representative (with certain exceptions), when required by the U. S. Secretary of Health and Human Services to investigate or determine our compliance with the law, and when otherwise required by law. Wolfpack Insurance Services may disclose your PHI without your prior authorization in response to the following:
· Court order;
· Order of a board, commission, or administrative agency for purposes of adjudication pursuant to its lawful authority;
· Subpoena in a civil action;
· Investigative subpoena of a government board, commission, or agency;
· Subpoena in an arbitration;
· Law enforcement search warrant; or
· Coroner's request during investigations.
Some other examples include: to notify or assist in notifying a family member, another person, or a personal representative of your condition; to assist in disaster relief efforts; to report victims of abuse, neglect or domestic violence to appropriate authorities; for organ donation purposes; to avert a serious threat to health or safety; for specialized government functions such as military and veterans activities; for workers' compensation purposes; and, with certain restrictions, we are permitted to use and/or disclose your PHI for underwriting, provided it does not contain genetic information. Information can also be de-identified or summarized so it cannot be traced to you and, in selected instances, for research purposes with the proper oversight.
Disclosures Wolfpack Insurance Services makes with your authorization
Wolfpack Insurance Services will not use or disclose your PHI without your prior written authorization unless permitted by law. If you grant an authorization, you can later revoke that authorization, in writing, to stop the future use and disclosure. The authorization will be obtained from you by Wolfpack Insurance Services or by a person requesting your PHI from Wolfpack Insurance Services.
YOUR RIGHTS REGARDING PHI
You have the right to request an inspection of and obtain a copy of your PHI.
You may access your PHI by contacting Wolfpack Insurance Services at the address at the bottom of this notice. You must include (1) your name, address, telephone number and identification number, and (2) the PHI you are requesting. Wolfpack Insurance Services may charge a reasonable fee for providing you copies of your PHI. Wolfpack Insurance Services will only maintain that PHI that we obtain or utilize in providing your health care benefits. Most PHI, such as treatment records or x-rays, is returned by Wolfpack Insurance Services to the dentist after we have completed our review of that information. You may need to contact your health care provider to obtain PHI that Wolfpack Insurance Services does not possess.
You may not inspect or copy PHI compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, or PHI that is otherwise not subject to disclosure under federal or state law. In some circumstances, you may have a right to have this decision reviewed. Please contact Wolfpack Insurance Services as noted below if you have questions about access to your PHI.
You have the right to request a restriction of your PHI.
You have the right to ask that we limit how we use and disclose your PHI, however, you may not restrict our legal or permitted uses and disclosures of PHI. While we will consider your request, we are not legally required to accept those requests that we cannot reasonably implement or comply with during an emergency. If we accept your request, we will put our understanding in writing.
You have the right to correct or update your PHI.
You may request to make an amendment of PHI we maintain about you. In certain cases, we may deny your request for an amendment. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. If your PHI was sent to us by another, we may refer you to that person to amend your PHI. For example, we may refer you to your dentist to amend your treatment chart or to your employer, if applicable, to amend your enrollment information. Please contact the privacy office as noted below if you have questions about amending your PHI.
You have rights related to the use and disclosure of your PHI for marketing.
Wolfpack Insurance Services agrees to obtain your authorization for the use or disclosure of PHI for marketing when required by law. You have the opportunity to opt-out of marketing that is permitted by law without an authorization. Wolfpack Insurance Services does not use your PHI for fundraising purposes.
You have the right to request or receive confidential communications from us by alternative means or at a different address.
Alternate or confidential communication is available if disclosure of your PHI to the address on file could endanger you. You may be required to provide us with a statement of possible danger, as well as specify a different address or another method of contact. Please make this request in writing to the address noted at the end of this notice.
You have the right to receive an accounting of certain disclosures we have made, if any, of your PHI.
You have a right to an accounting of disclosures with some restrictions. This right does not apply to disclosures for purposes of treatment, payment, or health care operations or for information we disclosed after we received a valid authorization from you. Additionally, we do not need to account for disclosures made to you, to family members or friends involved in your care, or for notification purposes. We do not need to account for disclosures made for national security reasons, certain law enforcement purposes or disclosures made as part of a limited data set. Please contact us at the number at the end of this notice if you would like to receive an accounting of disclosures or if you have questions about this right.
You have the right to get this notice by email.
A copy of this notice is posted on the Wolfpack Insurance Services website. You may also request an email copy or paper copy of this notice by calling our Customer Service number listed at the bottom of this notice.
You have the right to be notified following a breach of unsecured protected health information.
Wolfpack Insurance Services will notify you in writing, at the address on file, if we discover we compromised the privacy of your PHI.
You may file a complaint with Wolfpack Insurance Services and/or with the U. S. Secretary of Health and Human Services if you believe Wolfpack Insurance Services has violated your privacy rights. Complaints to Wolfpack Insurance Services may be filed by notifying the contact below. We will not retaliate against you for filing a complaint.
You may contact Wolfpack Insurance Services at 800-296-0192, or you may write to the address listed below for further information about the complaint process or any of the information contained in this notice.
Wolfpack Insurance Services
P.O. Box 156
Belmont, CA 94002
This notice is effective on and after January 1, 2016.
For notices from Delta Dental and/or VSP please log onto their web sites.
For notices from Delta Dental and/or VSP please log onto their web sites.