Page 16 - 2016 WFF Guide 1
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R em em b er: K eep thi s C redi tab le H I P A A C omprehensiv e N otice of P riv acy
C ov erage n oti c e. I f you dec i de to j oi n P olicy and P roced ures
on e of the M edi c are drug p lan s, you
m ay b e req ui red to p rov i de a c op y I mportant N otice— C omprehensiv e N otice of P riv acy
of thi s n oti c e w hen you j oi n to show P olicy and P roced ures
w hether or n ot you hav e m ai n tai n ed
c redi tab le c ov erage an d w hether or T hi s n oti c e desc ri b es how m edi c al i n f orm ati on ab out you m ay b e used
n ot you are req ui red to p ay a hi gher an d di sc losed an d how you c an get ac c ess to thi s i n f orm ati on . Please
p rem i um ( a p en alty) . rev i ew i t c aref ully.
D ate: O ctober, 2 0 1 5 This N otice is prov id ed to you on behalf of: the C ompany C omprehensiv e
Contact—Position/Ofice: Beneits Employee Welfare Beneit Plan*
A d ministrator
A d d ress: 2 1 1 S outh J efferson A v enue The P lan’ s D uty to S afeguard Y our P rotected H ealth I nformation
S t. L ouis, M O 6 3 1 0 3 Individually identiiable information about your past, present, or future health or
P hone N umber: 3 1 4 .5 8 4 .6 6 2 9 cond ition, the prov ision of health care to you, or payment for the health care is
consid ered “ P rotected H ealth I nformation” ( “ P H I ” ) . The P lan is req uired to ex tend
N othi n g i n thi s n oti c e gi v es you or your certain protections to your P H I , and to giv e you this N otice about its priv acy
dep en den ts a ri ght to c ov erage un der practices that ex plains how , w hen, and w hy the P lan may use or d isclose your
the Plan . Y our ( or your dep en den ts’ ) PHI. Except in speciied circumstances, the Plan may use or disclose only the
ri ght to c ov erage un der the Plan i s minimum necessary P H I to accomplish the purpose of the use or d isclosure.
determ i n ed solely un der the term s of
the Plan . The P lan is req uired to follow the priv acy practices d escribed in this N otice,
though it reserv es the right to change those practices and the terms of this
M aternity and N ew born N otice at any time. I f it d oes so, and the change is material, you w ill receiv e a
I nfant C ov erage rev ised v ersion of this N otice either by hand d eliv ery, mail d eliv ery to your last
k now n ad d ress, or some other fashion. This N otice, and any material rev isions
G roup health plans and health insurance of it, w ill also be prov id ed to you in w riting upon your req uest ( ask your H uman
issuers generally may not, und er fed eral Resources representative, or contact the Plan’s Privacy Oficial, described below),
law, restrict beneits for any hospital length and w ill be posted on any w ebsite maintained by the C ompany that d escribes
of stay in connection w ith child birth for beneits available to employees and dependents.
the mother or new born child to less than
4 8 hours follow ing a v aginal d eliv ery, or Y ou may also receiv e one or more other priv acy notices from insurance
less than 9 6 hours follow ing a caesarian companies that provide beneits under the Plan. Those notices will describe how
section. H ow ev er, fed eral law generally the insurance companies use and d isclose P H I and your rights w ith respect to the
d oes not prohibit the mother’ s or new born’ s P H I they maintain.
attend ing prov id er, after consulting w ith the H ow the P lan M ay U se and D isclose Y our P rotected H ealth
mother, from d ischarging the mother or her I nformation
new born earlier than 4 8 hours ( or 9 6 hours
as applicable) . I n any case, plans and issuers The P lan uses and d iscloses P H I for a v ariety of reasons. F or its routine uses
may not, und er fed eral law , req uire that a and d isclosures it d oes not req uire your authoriz ation, but for other uses
prov id er obtain authoriz ation from the plan and d isclosures, your authoriz ation ( or the authoriz ation of your personal
or the issuer for prescribing a length of stay representativ e ( e.g., a person w ho is your custod ian, guard ian, or has your
not in ex cess of 4 8 hours ( or 9 6 hours) . pow er- of- attorney) may be req uired . The follow ing offers more d escription and
ex amples of the P lan’ s uses and d isclosures of your P H I .
R em em b er: K eep thi s C redi tab le H I P A A C omprehensiv e N otice of P riv acy
C ov erage n oti c e. I f you dec i de to j oi n P olicy and P roced ures
on e of the M edi c are drug p lan s, you
m ay b e req ui red to p rov i de a c op y I mportant N otice— C omprehensiv e N otice of P riv acy
of thi s n oti c e w hen you j oi n to show P olicy and P roced ures
w hether or n ot you hav e m ai n tai n ed
c redi tab le c ov erage an d w hether or T hi s n oti c e desc ri b es how m edi c al i n f orm ati on ab out you m ay b e used
n ot you are req ui red to p ay a hi gher an d di sc losed an d how you c an get ac c ess to thi s i n f orm ati on . Please
p rem i um ( a p en alty) . rev i ew i t c aref ully.
D ate: O ctober, 2 0 1 5 This N otice is prov id ed to you on behalf of: the C ompany C omprehensiv e
Contact—Position/Ofice: Beneits Employee Welfare Beneit Plan*
A d ministrator
A d d ress: 2 1 1 S outh J efferson A v enue The P lan’ s D uty to S afeguard Y our P rotected H ealth I nformation
S t. L ouis, M O 6 3 1 0 3 Individually identiiable information about your past, present, or future health or
P hone N umber: 3 1 4 .5 8 4 .6 6 2 9 cond ition, the prov ision of health care to you, or payment for the health care is
consid ered “ P rotected H ealth I nformation” ( “ P H I ” ) . The P lan is req uired to ex tend
N othi n g i n thi s n oti c e gi v es you or your certain protections to your P H I , and to giv e you this N otice about its priv acy
dep en den ts a ri ght to c ov erage un der practices that ex plains how , w hen, and w hy the P lan may use or d isclose your
the Plan . Y our ( or your dep en den ts’ ) PHI. Except in speciied circumstances, the Plan may use or disclose only the
ri ght to c ov erage un der the Plan i s minimum necessary P H I to accomplish the purpose of the use or d isclosure.
determ i n ed solely un der the term s of
the Plan . The P lan is req uired to follow the priv acy practices d escribed in this N otice,
though it reserv es the right to change those practices and the terms of this
M aternity and N ew born N otice at any time. I f it d oes so, and the change is material, you w ill receiv e a
I nfant C ov erage rev ised v ersion of this N otice either by hand d eliv ery, mail d eliv ery to your last
k now n ad d ress, or some other fashion. This N otice, and any material rev isions
G roup health plans and health insurance of it, w ill also be prov id ed to you in w riting upon your req uest ( ask your H uman
issuers generally may not, und er fed eral Resources representative, or contact the Plan’s Privacy Oficial, described below),
law, restrict beneits for any hospital length and w ill be posted on any w ebsite maintained by the C ompany that d escribes
of stay in connection w ith child birth for beneits available to employees and dependents.
the mother or new born child to less than
4 8 hours follow ing a v aginal d eliv ery, or Y ou may also receiv e one or more other priv acy notices from insurance
less than 9 6 hours follow ing a caesarian companies that provide beneits under the Plan. Those notices will describe how
section. H ow ev er, fed eral law generally the insurance companies use and d isclose P H I and your rights w ith respect to the
d oes not prohibit the mother’ s or new born’ s P H I they maintain.
attend ing prov id er, after consulting w ith the H ow the P lan M ay U se and D isclose Y our P rotected H ealth
mother, from d ischarging the mother or her I nformation
new born earlier than 4 8 hours ( or 9 6 hours
as applicable) . I n any case, plans and issuers The P lan uses and d iscloses P H I for a v ariety of reasons. F or its routine uses
may not, und er fed eral law , req uire that a and d isclosures it d oes not req uire your authoriz ation, but for other uses
prov id er obtain authoriz ation from the plan and d isclosures, your authoriz ation ( or the authoriz ation of your personal
or the issuer for prescribing a length of stay representativ e ( e.g., a person w ho is your custod ian, guard ian, or has your
not in ex cess of 4 8 hours ( or 9 6 hours) . pow er- of- attorney) may be req uired . The follow ing offers more d escription and
ex amples of the P lan’ s uses and d isclosures of your P H I .
