Health Plan Notice of Privacy Practices

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires health plans to notify participants about its policies and practices to protect the confidentiality of your health information. This is a summary of the Memorial Hospital Inc. Health Plan Privacy Notice. This is also a reminder that you have the right to obtain an inclusive copy of our Privacy Notice describing how your protected health information may be used or disclosed by the Memorial Medical Inc. Health Plan to carry out payment, health care operations, and for other purposes that are permitted or required by federal law. A copy of the Privacy Notice can be obtained from our Privacy Official. You can also access it at www.memorialmedcenter.org

Memorial Hospital Inc Health Plan needs to create, receive and maintain records that contain health information about you to administer the plan and to provide you with health care benefits. Memorial Hospital Inc. Health Plan may receive personal health information from you, your physicians, hospitals, and others who provide you with health care services. Memorial Hospital Inc Health Plan is required to keep this information confidential. The following is a summary of the ways Memorial Hospital Inc Health Plan may use and disclose health information about you, describes your rights, and the obligations Memorial Hospital Inc Health Plan has regarding the use and disclosure of your health information.

Memorial Hospital Inc Health Plan May Use and Disclose Your Health Information:

• To provide treatment.
• To obtain payment.
• To conduct health care operations.

For example, Memorial Hospital Inc Health Plan may use your health information to evaluate a request for coverage or a claim for benefits; to evaluate quality; and improve health care operations. Memorial Hospital Inc. Health Plan may use and disclose your health information to determine eligibility for benefits; to facilitate payment for treatment you receive from health care providers or to assist them to provide you with treatment. Memorial Hospital Inc Health Plan may disclose your health information to entities to assist with the processing or subrogation of health claims or with another health plan or insurance company to coordinate benefit payments. Memorial Hospital Inc Health Plan may also make other uses and disclosures of your health information as required by law or as permitted by our policies.

Your Rights Regarding Health Information About You

You have the following rights regarding your health information:

• Right to inspect and copy your health information.
• Right to amend your health information
• Right to an accounting.
• Right to request restrictions.
• Right to receive confidential communications.
• Right to a paper copy of the Notice of Privacy Practices.

You generally have a right to access and in certain instances to correct information. This does not apply to information collected in connection with, or in anticipation of, any claim or legal proceeding.

Privacy Obligations

Memorial Hospital Inc Health Plan is required by law to:

• Make sure that health information that identifies you is kept private.
• Give you a Notice of our legal duties and privacy practices with respect to health information about you.
• Follow the terms of the Notice that is currently in effect.

Contact Information

For more information about Memorial Hospital Inc Health Plan Privacy Notice or about our privacy policies, please contact:
Tammie Zarak - Plan Privacy Official at 715.743.3101 ext. 166.

Effective Date

Memorial Hospital Inc. Health Plan Notice of Privacy Practices was originally effective [April 14, 2004]. The current notice is effective April 14, 2007.