Moline-Coal Valley School District No. 40

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Privacy Practices Notice

Privacy Practices Notice

BOARD OF EDUCATION OF MOLINE SCHOOL DISTRICT NO. 40 SELF-INSURED HEALTH PLAN

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

PLEASE REVIEW THIS NOTICE CAREFULLY.

The Board of Education of Moline School District No. 40 (“District”) recognizes the importance of keeping your health information private and secure. The District is required by the Health Insurance Portability and Accountability Act (“HIPAA”) to maintain the privacy of your protected health information (“PHI”). Generally, PHI is information that is created or received by a health plan, employer, health care provider or health care clearing house that may identify you and that relates to (1) your past, present or future physical or mental health or condition or (2) the provision of health care to you or (3) the past, present or future payments for health care provided to you. In addition, the District is required to provide you with notice of our legal duties and privacy practices with respect to PHI, and to inform you of your legal rights concerning PHI.

This Notice shall become effective April 14, 2003. The District is required to abide by the terms of this Notice for as long as it is in effect. The District reserves the right to modify the privacy practices and terms described in this Notice at any time. Any modifications to our privacy practices will apply to PHI that we already maintain about you as well as any information that we may receive or create in the future. In the event modifications are made to our privacy practices, copies of revised notices will be mailed to all eligible employees and retirees. A copy of this notice will be posted at the Administrative Offices at Allendale.

Procedures in Place to Protect the Privacy of Your PHI

The District’s top priority is to keep your PHI safe and secure. We achieve this goal by limiting access to your PHI to only those persons who need it to perform the duties of their position and such individuals are provided training on our privacy and security policies. In addition, we maintain appropriate safeguards to protect your PHI. For example, we protect access to our buildings and computer systems.

Use and Disclosure of Your PHI for Treatment, Payment or Health Care Operations

In order to ensure that you receive the proper benefits, the District may use and disclose your PHI for treatment, payment and health care operations.

1. Treatment – The District may use and disclose your PHI to a physician or other health care provider providing treatment to you.

2. Payment – We may use and disclose your PHI for the purpose of obtaining premiums or to determine or fulfill our responsibility to provide you with insurance coverage or benefits pursuant to your insurance policy. For example, we may use and disclose your PHI in order to determine your eligibility or coverage pursuant to your policy or to adjudicate claims.

3. Health Care Operations – We may use and disclose your PHI in connection with the operation of this health plan. For example, we may use and disclose your PHI to review the competence or qualifications of a health care provider or to evaluate provider and health plan performance.

Other Uses and Disclosures in Limited Circumstances

1. Disclosures Required by Law. The District will use and disclose your PHI when required to do so by federal, state or local law.

2. Business Associates. The District will use and disclose your PHI to our business associates, such as our third-party administrators, accountants, provided that those business associates have executed a written agreement concerning the appropriate use and disclosure of your PHI.

3. Uses and Disclosure of PHI Made Pursuant to Your Written Authorization. The District may, provided you give us written authorization to do so, use or disclose your PHI to anyone for any purpose that you have authorized. If you grant the District such authorization, you may revoke it in writing at any time. Your revocation will not invalidate any use or disclosure permitted by your authorization while it was in effect. If you do not authorize such use or disclosure, the District may only use and disclose your PHI under the circumstances described in this notice.

4. Disclosure to Your Family, Friends and Other Persons. The District may, with your consent, disclose your PHI to a family member, friend or other person identified by you to the extent necessary to assist with your healthcare or with payment for your healthcare. In addition, the District may also, with your consent, use or disclose your PHI to notify, or assist in giving notice of your location, general condition or death to your family members, your personal representative, or other persons responsible for your care.

5. Law Enforcement. We may use or disclose your PHI for a law enforcement purpose to a law enforcement official if certain pre-conditions are satisfied. For example, we may disclose your PHI: (1) in accordance with laws that require the reporting of certain types of wounds or other physical injuries; (2) in response to a law enforcement official’s request for such information for the purpose of identifying or locating a suspect, fugitive, material witness, or missing person; (3) in response to a law enforcement official’s request for such information about an individual who is or is suspected to be a victim of a crime.

6. Public Health Activities. The District may use or disclose your PHI to public health authorities for the purpose of providing them with notice of public health risks such as potential exposure to a communicable disease or to report child abuse or neglect.

7. Prevention of Abuse, Neglect or Domestic Violence. To the extent required or authorized by law, the District may disclose your PHI to a government authority (authorized by law to receive such information) if we reasonably believe that you are a victim of abuse, neglect or domestic violence.

8. Health Oversight Activities. The District may disclose your PHI to a health oversight agency for oversight activities authorized by law, such as civil or criminal investigations or other activities necessary for the appropriate oversight of the health care system.

9. Judicial and Administrative Proceedings. The District may disclose your PHI to a court or administrative body in response to an order of the court or administrative body, a subpoena, discovery request or other lawful process.

10. Decedents. The District may disclose your PHI to a coroner, medical examiner or funeral director as necessary to carry out their duties, as authorized by law, with respect to the decedent.

11. Donation/Transplantation of Organs, Eyes or Tissue. The District may disclose your PHI to an organ procurement organization for the purpose of facilitating organ, eye or tissue donation or transplantation.

12. Research Organizations. The District may disclose your PHI to research organizations for research purposes provided certain preconditions are satisfied.

13. Prevention of Serious Threat to Health or Safety. The District may disclose your PHI, consistent with applicable law and standards of ethical conduct, to law enforcement authorities, or persons that are reasonably able to prevent or lessen the threat, when the District, in good faith, believes that such disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of an individual or the public.

14. Specialized Government Functions. The District may use or disclose your PHI, under certain circumstances, to military authorities (if you are a member of the Armed Forced personnel) or other authorized federal officials that are required for lawful intelligence, counterintelligence, and other national security activities.

15. Workers’ Compensation. The District may use or disclose your PHI as necessary to comply with workers’ compensation laws.

YOUR RIGHTS WITH RESPECT TO PHI

1. Right to Request Restrictions on Use and Disclosure of Your PHI. You have the right to request additional restrictions on the District’s use or disclosure of your PHI. However, the District is not required to grant your request. In the event the District does grant your request, we are bound to that agreement except when otherwise required by law, or in emergency situations when the PHI is necessary for your treatment. Your request must clearly describe (a) the information that you want restricted, (b) whether you are requesting to limit our use or disclosure or both; and (c) to whom you want these restrictions to apply.

2. Right to Receive Confidential Communications of PHI by Alternative Means. You have the right to receive confidential communications of your PHI from the District by alternative means or at alternative locations, provided that the request is reasonable under the circumstances, and you clearly state that the disclosure of all or part of your PHI could endanger you. For example, you may prefer to have the District send all communications to your home address as opposed another address. All such requests must be submitted to the Privacy Officer.

3. Right to Inspect and Copy. You have a right to access your health information, with limited exceptions. Certain requests for access to your PHI must be in writing, state that you want access to your PHI and must be signed by you or your representative. In addition, you have the right, upon written request, to inspect and copy certain PHI that may be used to make decisions about your insurance coverage, including medical and billing records, but excluding psychotherapy notes. The District may deny your request to inspect and/or copy in specific limited circumstances. In such circumstances, you may have the right to have such denials reviewed. The District may impose reasonable fees it incurs for the reproduction of documents requested by you.

4. Right to Amend Your PHI. You have the right to request the District to amend your PHI. Your request must be in writing and clearly describe your reasons in support of the requested amendment. Your request must be sent to the Privacy Officer. Under certain circumstances, the District may deny your request.

5. Right to Request Accounting of Disclosures. You have the right to request a list of certain disclosures that the District has made of your PHI for purposes other than treatment, payment or healthcare operations and certain other activities. Your request must be in writing and will cover all disclosures made within the last 6 years from the date the accounting is requested, but not before April 14, 2003. You are entitled to one free accounting request per 12 month period. If you request more than one request in a 12 month period the District may charge you a reasonable cost based fee for responding to these additional requests.

6. Right to Receive a Hardcopy of this Notice. An electronic copy of this Notice is available on the District’s web site at: www.molineschools.org If you would like to receive a hard copy of this notice, please contact the District’s Privacy Officer.

QUESTIONS, SUGGESTIONS OR COMPLAINTS

Contact the Privacy Officer at the address listed below if you would like further information about the policies and practices described in this Notice or if you have any questions or suggestions.

If you believe that the District violated your privacy rights, you may file a complaint with the Privacy Officer listed below or you may file a complaint with the U.S. Department of Health and Human Services. Your complaint must be in writing and clearly describe how your rights were violated. The District will not retaliate against you for filing a complaint with our Privacy Officer listed below or the U.S. Department of Health and Human Services.

DISTRICT PRIVACY OFFICER

Title Insurance Secretary
Address Insurance Office – Allendale
1619 – 11th Avenue
Moline, IL 61265
Telephone Number (309) 743-8115