Page 16 - Flyer Employer Benefits Brochure - Final 2021 w_compliance notices

 Prescription drug coverage

 Health care spending account program
 Employee Assistance program
 Wellness program

The Plan’s actions and obligations are undertaken by your employer’s employees as well as certain third parties who perform
services for the Plan. However, your employer’s employees perform only limited Plan functions – most Plan administrative
functions are performed by third party service providers.

Protected Health Information

Federal law requires us to have a special policy for safeguarding certain medical information called “Protected Health
Information.” Protected Health Information (PHI) is health information (including genetic information) received or created
in the course of administering the Plan, that can be used to identify you and that relates to:
 your physical or mental health condition,
 the provision of health care to you, or
 payment for your health care.

Your medical and dental records, your claims for medical and dental benefits, and the explanation of benefits (EOB) sent in
connection with payment of your claims are all examples of PHI.

If your employer obtains your health information in another way – for example, if you are hurt in a work accident or if you
provide medical records with your request for Family and Medical Leave Act (FMLA) absence--then your employer will
safeguard that information in accordance with other applicable laws, but such information is not considered PHI subject to
this notice. Similarly, health information obtained by a non-health-related benefits program, such as the long-term disability
program or accidental death and dismemberment program, is not protected under this notice. This notice does not apply in
those situations because the health information is not received or created in connection with the Plan.

The remainder of this notice generally describes our rules with respect to your PHI received or created by the Plan.
Your Rights

When it comes to your PHI, you have certain rights. This section explains your rights and some of our responsibilities to
help you.
Get a copy of health and claims records

• You can ask to see or obtain a copy of your health and claims records and other PHI we have about you. Ask us how
to do this.
• We will provide a copy or a summary of your health and claims records, usually within 30 days of your request. We

may charge a reasonable, cost-based fee.
Ask us to correct health and claims records

• You can ask us to correct your health and claims records if you think they are incorrect or incomplete. Ask us how to
do this.
• We may say “no” to your request, but we’ll tell you why in writing within 60 days.

Request confidential communications

• You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different
address.
• We will consider all reasonable requests and must say “yes” if you tell us you would be in danger if we do not.
Ask us to limit what we use or share

• You can ask us not to use or share certain PHI for treatment, payment, or our operations.
• We are not required to agree to your request, and we may say “no” if it would affect your care.