AVESIS INSURANCE INCORPORATED
3724 North Third Street, Suite 300 · Phoenix, Arizona 85012
800-522-0258 · fax: 602-240-9103
(Herein called the Company, We, Us, or Our)

HIPAA Notice of Privacy Practices

THIS NOTICE DESCRIBES HOW PROTECTED HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

This notice describes how we protect personal health information we have about you which relates to our vision coverage. “Protected Health Information” is individually identifiable information about You. All of the following are examples of Protected Health Information: demographic information like Your name, address and social security number; medical information that relates to Your past, present or future physical health that is collected, created or received from You, a health care provider, a health plan, employer or a health care clearinghouse; the providing of health care; or the past present or future payment for providing health care to You.

Our Legal Duty
We are required by applicable federal and state laws to maintain the privacy of your Protected Health Information. We are also required to give You this notice about our privacy practices, our legal duties, and your rights concerning your Protected Health Information. We must follow the privacy practices that are described in this notice while it is in effect. This notice takes effect April 14, 2003 or the date coverage became effective for you, whichever is later, and will remain in effect until we replace it.

We reserve the right to change our privacy practices and the terms of this notice at any time, provided such changes are permitted by applicable law. We reserve the right to make the changes in our privacy practices and the new terms of our notice effective for all Protected Health Information that we maintain, including Protected Health Information we created or received before we made the changes. Before we make a significant change in our privacy practices, we will change this notice and send the new notice to our Insureds at the time of change. You may request a copy of our notice at any time. For more information about our privacy practices, or for additional copies of this notice, please contact us using the information listed at the end of this notice.

Uses and Disclosures of Your Protected Health Information
In conducting our business we will create records regarding you and the insurance services we provide you. The main reasons for which we may use and may disclose your Protected Health Information are to evaluate and process any requests for medical coverage and claims for benefits you may make. The following describe these and other uses and disclosures, together with some examples:

Treatment: We may use or disclose your Protected Health Information to facilitate treatment by providers. For example, your Protected Health Information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to treat you. We may request the services of a business associate to assist us in these activities.

Payment: We may use and disclose your Protected Health Information to facilitate payment of benefits under your insurance coverage. For example, we might disclose your Protected Health Information to determine your eligibility for benefits, to coordinate benefits, to examine medical necessity, to obtain payments and to issue explanations of benefits. We also may use your Protected Health Information to obtain payment from third parties that may be responsible for your premium payments, such as family members.

Health Care Operations: We may use and disclose Your Protected Health Information as necessary, and as permitted by law, to operate our business. Health care operations include: (a) rating our risk and determining our premiums for your insurance; (b) conducting quality assessment and improvement activities; (c) conducting or arranging for medical review, legal services, audit services, fraud and abuse detection and compliance programs; (d) business planning and development.

On Your Authorization: You may give us written authorization to use your Protected Health Information or to disclose it to anyone for any purpose. If you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosure permitted by your authorization while it was in effect. Unless you give us a written authorization, we cannot use or disclose your Protected Health Information for any reason except those described in this notice.

To Your Family and Friends: We may disclose your Protected Health Information to a family member, friend, or other person to the extent necessary to help with your health care or for payment of your health care. We may use or disclose your name, location and general condition or death to notify, or assist in the notification, of (including identifying or locating) a person involved in your care.

Before we disclose your Protected Health Information to a person involved with your health care or payment for your health care, we will provide you with an opportunity to object to such uses or disclosures. If you are not present, or in the event of your incapacity or an emergency, we will disclose your Protected Health Information based on our professional judgment of whether the disclosure would be in your best interest.

Your Employer or Organization Sponsoring Your Health Plan: We may disclose your Protected Health Information and the Protected Health Information of others enrolled in your group insurance plan to the employer or other organization that sponsors your group insurance plan to permit the plan administrator to perform plan administration functions. We may also disclose summary information about the enrollees in your group insurance plan to the plan administrator to use to obtain premium bids for the health insurance coverage offered through your group insurance plan or to decide whether to modify, amend or terminate your group insurance plan. The summary information we may disclose will summarize claims history, claims expenses, or types of claims experienced by the enrollees in your group insurance plan. The summary information will be stripped of demographic information about the enrollees in the group insurance plan, but the plan administrator may still be able to identify you or other participants in your group health plan from the summary information. We may also disclose enrollment and disenrollment information to either the plan administrator or plan sponsor of your group insurance plan.

Underwriting: We may receive your Protected Health Information for underwriting, premium rating or other activities relating to the creation, renewal or replacement of a contract of health insurance or health benefits. We will not use or further disclose this Protected Health Information for any other purpose, except as required by law, unless the contract of health insurance or health benefits is placed with us. Our use and disclosure of your Protected Health Information will only be as described in this notice.

Public Benefit: We may use or disclose your Protected Health Information as authorized by law for the following purposes deemed in the public interest or benefit:

• as required by law;
• for public health activities, including disease and vital statistic reporting, child abuse reporting; FDA oversight, and to employers regarding work-related illness or injury;
• to report adult abuse, neglect, or domestic violence;
• to health oversight agencies;
• in response to court and administrative orders and other lawful processes;
• to law enforcement officials pursuant to subpoenas and other lawful processes, concerning crime victims, suspicious deaths, crimes on our premises, reporting crimes in emergencies, and for purposes of identifying or locating a suspect or other person;
• to coroners, medical examiners, and funeral directors;
• to organ procurement organizations;
• to avert a serious threat to health and safety;
• to the military and to federal officials for lawful intelligence, counterintelligence, and national security activities;
• to correctional institutions regarding inmates; and
• as authorized by state worker’s compensation laws.

Business Associates: Certain aspects and components of our business are preformed through contracts with outside persons or organizations. Examples of these outside persons and organizations include our third party administrator, financial auditors, actuarial and underwriting services; legal services and microfilm service. At times it may be necessary for us to provide your Protected Health Information to one or more of these outside persons or organizations who assist us with our health care operations. In all cases, we require these business associates to appropriately safeguard the privacy of your information.

Individual Rights
Access: In most cases, you have the right to inspect and obtain a copy of the Protected Health Information that we maintain about you. To inspect and copy Protected Health Information, you must submit your request in writing using the “Contact Information” provided at the end of this Notice. To receive a copy of your Protected Health Information, you may be charged a fee for the costs of copying, mailing or other supplies associated with your request. However, certain types of Protected Health Information will not be made available for inspection and copying. This includes psychotherapy notes and Protected Health Information collected by us in connection with, or in reasonable anticipation of any claim or legal proceeding. In very limited circumstances we may deny your request to inspect and obtain a copy of your Protected Health Information. If we do, you may request that the denial be reviewed. The review will be conducted by an individual chosen by us who was not involved in the original decision to deny your request. We will comply with the outcome of that review.

Disclosure Accounting: You have the right to receive a list of instances in which we or our business associates disclosed your Protected Health Information for purposes other than for treatment, payment, health care operations or as otherwise authorized by you since April 14, 2003 or the date coverage became effective for you, whichever is later. For example, we would account for your Protected Health Information or demographic information we disclose during an audit by an insurance department or pursuant to a court order. You must make your request in writing using the “Contact Information” provided at the end of this Notice. If you request this accounting more than once in a 12-month period, we may charge you a reasonable, cost-based fee for responding to these additional requests. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.

Restriction: You have the right to request a restriction or limitation on Protected Health Information we use or disclose about you for treatment, payment or health care operations, or that we disclose to someone who may be involved in your care or payment for your care, like a family member or friend. While we will consider your request, we are not required to agree to it. If we do agree to it, we will comply with your request. To request a restriction, you must make your request in writing using the “Contact Information” provided at the end of this Notice. In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit our use, disclosure or both; and (3) to whom you want the limits to apply (for example, disclosures to your spouse or parent). We will not agree to restrictions on Protected Health Information uses or disclosures that are legally required, or which are necessary to administer our business.

Confidential Communications: You have the right to request that we communicate with you about Protected Health Information in a certain way or at a certain location if you tell us that communication in another manner may endanger you. For example, you can ask that we only contact you at work or by mail. To request confidential communications, you must make your request in writing using the “Contact Information” provided at the end of this Notice and specify how or where you wish to be contacted. We will accommodate all reasonable requests.

Amendment: If you believe that your Protected Health Information is incorrect or that an important part of it is missing, you have the right to ask us to amend your Protected Health Information while it is kept by or for us. You must provide your request and your reason for the request in writing using the “Contact Information” provided at the end of this Notice. We may deny your request if it is not in writing or does not include a reason that supports the request. In addition, we may deny your request if you ask us to amend Protected Health Information that: (a) is accurate and complete; (b) was not created by us, unless the person or entity that created the Protected Health Information is no longer available to make the amendment; (c) is not part of the Protected Health Information kept by or for us; or (d) is not part of the Protected Health Information which you would be permitted to inspect and copy.

Right to File a Complaint: If you believe your privacy rights have been violated, you may file a complaint with us or with the Secretary of the Department of Health and Human Services. To file a complaint with us, submit your complaint using the “Contact Information” provided at the end of this Notice. All complaints must be submitted in writing. You will not be retaliated against for filing a complaint.

Contact Information: If you have questions regarding this Notice or need further assistance regarding this Notice, please contact us using the information listed below:

Contact Office: Avesis Insurance Incorporated, HIPAA Customer Service
Telephone: 800-643-1132, ext. 307 Fax: 602-240-9103

Address:
3724 North Third Street
Suite 300
Phoenix, Arizona 85012