DentalandVisionIns.com
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.
COMPLAINTS
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.
CONTACTS
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.