Insurance Privacy Notice

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

The City of Lewisville Health Benefit Trust is required by law to maintain the privacy of your protected health information and to provide you with notice of its legal duties and privacy practices with regard to your protected health information. As your group health plan, the City of Lewisville Health Benefit Trust must use and disclose protected health information in order to pay benefits to you and your health care providers. The City of Lewisville Health Benefit Trust uses physical, electronic, and procedural safeguards to protect your personal information from being used or disclosed inappropriately.

What is protected health information?
Protected health information is individually identifiable health information that is transmitted or maintained in writing, electronically, orally, or by any other means. It includes information created or received by the City of Lewisville Health Benefit Trust that identifies a person and relates to the person’s participation in the plan, the person’s physical or mental health, the provision of health care services to that person, or the payment of health care services received by the person.

How does the City of Lewisville Health Benefit Trust use and disclose protected health information?
The most common use of protected health information by the City of Lewisville Health Benefit Trust is for treatment, payment, and health care operations. The City of Lewisville Health Benefit Trust also may disclose protected health information to health care providers, other health plans, and health care clearinghouses for treatment, payment, and health care operations. (Health care clearinghouses are organizations that assist in electronic claims transactions.) The City of Lewisville Health Benefit Trust also may disclose protected health information to a business associate if the business associate needs the information to perform treatment, payment, or health care operations on the City of Lewisville Health Benefit Trust’s behalf. Health care providers, other health plans, health care clearinghouses, and the City of Lewisville Health Benefit Trust business associates are all required to maintain the privacy and confidentiality of the protected health information they receive from the City of Lewisville Health Benefit Trust. All uses and disclosures of protected health information made by the City of Lewisville Health Benefit Trust for treatment, payment, and health care operations are kept to the minimum necessary to accomplish the intended purpose.

What are treatment, payment, and health care operations?
Treatment is the provision, coordination, or management of health care and related services. An example of a disclosure of protected health information for treatment is when your family doctor refers you to a specialist.

Payment includes City of Lewisville Health Benefit Trust activities such as billing, claims management, subrogation, plan reimbursement, reviews for medical necessity and appropriateness of care, utilization review, and precertification of health care services. For example, the City of Lewisville Health Benefit Trust may tell a doctor whether you are eligible for coverage and what percentage of the bill the City of Lewisville Health Benefit Trust will pay.

Health care operations include quality assessment and improvement, reviewing competence or qualifications of health care professionals, underwriting, and other activities necessary to create or renew health plans. It also includes disease management, case management, conducting or arranging for medical review, legal services, auditing functions including fraud and abuse compliance programs, business planning and development, business management and general administrative activities. For example, the City of Lewisville Health Benefit Trust may use information from your claims to contact you about treatment alternatives or other health-related benefits and services that may be of interest to you.

How else does City of Lewisville Health Benefit Trust use and disclose protected health information?
City of Lewisville Health Benefit Trust may use or disclose protected health information, when permitted or required by law, as follows:

� Directly to you or your personal representative. A personal representative is a person who has legal authority to make health care decisions on your behalf. In the case of a child under 18 years of age, your personal representative may be a parent, guardian, or conservator. In the case of an adult, a personal representative may be a person who has a durable power of attorney to make health care decisions in the event you are incapacitated.
� To the Secretary of the U.S. Department of Health and Human Services to investigate or determine City of Lewisville Health Benefit Trust’s compliance with privacy regulations.
� To your family member, other relative, close personal friend, or other person identified by you that is directly involved in your care. Such disclosures will be limited to information relevant to the person’s involvement in your care and, except in the case of an emergency or your incapacity, you will be given an opportunity to agree or to object to the disclosure.
� For public health activities.
� To report suspected abuse, neglect, or domestic violence to public authorities.
� To a public oversight agency.
� When required for judicial or administrative proceedings.
� When required for law enforcement purposes.
� To organ procurement organizations or other organizations to facilitate organ, eye, or tissue donation or transplantation.
� To a coroner or medical examiner for the purpose of identifying a deceased person, determining a cause of death, or other duties required by law.
� To a funeral director when permitted by law and when necessary for the funeral director to carry out his/her duties with respect to the deceased person.
� To avert a serious threat to health or safety.
� For specialized government functions, as required by law.
� When otherwise required by law.
� Information that has been de-identified. This means that all individual identifiers have been removed and it is reasonable to believe that the organization receiving the information will not be able to identify the person to whom the information belongs.

Can I keep the City of Lewisville Health Benefit Trust from using or disclosing my protected health information for any of these purposes?
You have the right to make a written request that the City of Lewisville Health Benefit Trust not use or disclose your protected health information for certain purposes, unless the use or disclosure is required by law. However, since most of the uses and disclosures made by the City of Lewisville Health Benefit Trust are necessary to administer your health plan, the City of Lewisville Health Benefit Trust does not have to agree to your request.

Are there any other circumstances when City of Lewisville Health Benefit Trust may use or disclose protected health information?
The City of Lewisville Health Benefit Trust may not use or disclose your protected health information for any purpose not included in this notice, unless the City of Lewisville Health Benefit Trust first receives your written authorization. To be valid, an authorization must include: the name of the person or organization making the disclosure, the name of the person or organization receiving the disclosure, specifics on the information that may be disclosed, the purpose of the disclosure, and an end date or end event. You may revoke any authorization that you make. A revocation must be made in writing and will not apply to any information disclosed before the City of Lewisville Health Benefit Trust receives the revocation.

Will City of Lewisville Health Benefit Trust disclose my protected health information to my employer?
The City of Lewisville Health Benefit Trust is administered by your employer. However, the City of Lewisville Health Benefit Trust is prohibited from using or disclosing any protected health information for employment-related activities, if the protected health information was received or created while the City of Lewisville Health Benefit Trust was acting as your group health plan.

Can I find out if my protected health information has been disclosed to anyone?
You may make a written request to the City of Lewisville Health Benefit Trust’s Privacy Officer for an accounting of any disclosures of your protected health information made during the six years prior to receipt of your request. The accounting will not include any disclosures made for treatment, payment, or health care operations; any disclosures made directly to you; any disclosures made based upon your written authorization; any disclosures reported on a previous accounting; or any disclosures made before April 14, 2003 (April 14, 2004 for small health plans).

Generally, the accounting will be provided within 60 days of the date the City of Lewisville Health Benefit Trust receives your written request. However, the City of Lewisville Health Benefit Trust is allowed an additional 30 days if the City of Lewisville Health Benefit Trust notifies you, in writing, of the reason for the delay and notifies you of the date by which you can expect the accounting.

If you request more than one accounting within a 12-month period, the City of Lewisville Health Benefit Trust may charge a reasonable, cost-based fee for each additional accounting.

Can I view my protected health information maintained by City of Lewisville Health Benefit Trust?
You may make a written request to inspect, at the City of Lewisville Health Benefit Trust’s offices, your enrollment, payment, billing, claims, and case or medical management records maintained by the City of Lewisville Health Benefit Trust. You also may request paper copies of your records. If you request paper copies, the City of Lewisville Health Benefit Trust may charge a reasonable, cost-based fee for the copies. Requests to view your protected health information should be made in writing to:

CITY OF LEWISVILLE HEALTH BENEFIT TRUST

ATTN: MELINDA GALLER

P.O. BOX 299002

LEWISVILLE, TEXAS 75029

If I review my protected health information and find errors, how do I get my records corrected?
You may request that the City of Lewisville Health Benefit Trust amend any of your protected health information that the City of Lewisville Health Benefit Trust maintains. All requests for amendment must be made to the City of Lewisville Health Benefit Trust’s Privacy Officer, must be in writing, and must include a reason for the amendment. Please be aware that the City of Lewisville Health Benefit Trust can amend only the information that it creates. If your request is to amend information that the City of Lewisville Health Benefit Trust did not create, the City of Lewisville Health Benefit Trust will need a statement from the individual or organization that created the information explaining an error was made. For example, if you request a claim be amended because the diagnosis is incorrect, the City of Lewisville Health Benefit Trust will amend the claim if the City of Lewisville Health Benefit Trust made an error in the data entry of the diagnosis. However, if your health care provider submitted the wrong diagnosis to the City of Lewisville Health Benefit Trust, the City of Lewisville Health Benefit Trust cannot amend the claim without a statement from your health care provider that the diagnosis is incorrect.

The City of Lewisville Health Benefit Trust has 60 days after it receives your request to respond. If the City of Lewisville Health Benefit Trust is not able to respond, it is allowed one 30-day extension. If the City of Lewisville Health Benefit Trust denies your request, either in part or in whole, the City of Lewisville Health Benefit Trust will send you a written explanation for the denial. You may then submit a written statement disagreeing with the City of Lewisville Health Benefit Trust ’s denial and have that statement included in any future disclosures.

I’m covered as a dependent and do not want anything that includes my protected health information mailed to the covered employee’s address. Will you do that?
If mailing communications to the covered employee’s address could place you in danger, the City of Lewisville Health Benefit Trust will accommodate your request to receive communications of protected health information by alternative means or at alternative locations. Your request must be reasonable, must be in writing, must specify an alternative address or other method of contact, and must include a statement that sending communications to the covered employee’s address could place you in danger.

If I believe my privacy rights have been violated, how do I make a complaint?
If you believe your privacy rights have been violated, you may make a complaint to the City of Lewisville Health Benefit Trust at:

In writing: CITY OF LEWISVILLE HEALTH BENEFIT TRUST

ATTN: MELINDA GALLER

P.O. BOX 299002

LEWISVILLE, TEXAS 75029

Or call: 972-219-3450

Also, you may file a complaint with the U.S. Department of Health and Human Services at:

U.S. Department of Health and Human Services

Hubert H. Humphrey Building

200 Independence Avenue, S.W.

Washington, D.C. 20201

The City of Lewisville Health Benefit Trust will not retaliate against you for filing a complaint.

When are the privacy practices described in this notice effective?
This privacy notice has an effective date of April 14, 2003.

Can the City of Lewisville Health Benefit Trust change its privacy practices?
The City of Lewisville Health Benefit Trust is required by law to abide by the terms of the privacy notice currently in effect. The City of Lewisville Health Benefit Trust reserves the right to change its privacy practices and to apply the changes to any protected health information the City of Lewisville Health Benefit Trust received or maintained prior to the effective date of the change. The City of Lewisville Health Benefit Trust will provide each of you with any revised notice of privacy practices. The City of Lewisville Health Benefit Trust will distribute the notice to covered employees before the effective date of any changes. Also, the City of Lewisville Health Benefit Trust will maintain its current privacy notice on its web site at: www.cityoflewisville.com.

What happens to my protected health information when I leave the plan?
The City of Lewisville Health Benefit Trust is required to maintain your records for at least six years after you leave the City of Lewisville Health Benefit Trust’s group health plan. However, the City of Lewisville Health Benefit Trust will continue to maintain the privacy and confidentiality of your protected health information even after you leave the plan.

How can I get a paper copy of this notice?
To request that the City of Lewisville Health Benefit Trust mail you a paper copy of this notice, call 972-219-3450.

Who can I contact for more information on my privacy rights?
Write to: CITY OF LEWISVILLE HEALTH BENEFIT TRUST

ATTN: MELINDA GALLER

P.O. BOX 299002

LEWISVILLE, TEXAS 75029

Or call: 972-219-3450

�City of Lewisville All Rights Reserved	Thank you for your interest in Lewisville, TX	Privacy Policy, ADA Compliance
CONTACT US
151 W. Church Street 972-219-3400 - Phone 972-219-3410 - Fax