BENEFITS DESIGN GROUP, INC. ("BDG") NOTICE OF PRIVACY PRACTICESTHIS NOTICE DESCRIBES HOW YOUR MEDICAL INFORMATION MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
How Your Health Information May Be Used or Disclosed
The following categories describe the ways that Benefits Design Group, Inc. ("BDG"), as third party administrator of Medical Reimbursement FSA Plan or Health Reimbursement Arrangement HRA Plan (collectively the "Plan") claims, may use and disclose your health information. For each category of uses and disclosures, we will explain what we mean and present some examples. Not every use or disclosure in a category will be listed. However, all the ways we are permitted to use and disclose information will fall within one of the categories.
1. Plan Operation and Reimbursement Functions. As third party administrator of the Plan, we may use or disclose health information about you required to determine eligibility for plan benefits and to facilitate payment for qualified medical expenses as that term is defined in Code § 213. For example, reimbursement functions may include reviewing claims for health, dental, and/or vision services or products (as applicable to your plan type), to determine whether a particular claim requires additional doctor's verification, verification of tax dependent status, or determining whether a claim is covered under the applicable Plan.
2. Required by Law, as part of a Regulatory or Legal Proceeding, for Law Enforcement. We may use or disclose your health information when (i) required by federal, state or local law, such as an IRS audit; (ii) in response to a court or administrative order if you or your estate are involved in a legal dispute; or (iii) in response to a formal request by a law enforcement official such as a subpoena or warrant.
3. Disclosures to Plan Sponsors. We may disclose your health information to the sponsor of your group health plan for purposes of facilitating reimbursement of eligible expenses. In addition, medical information may be disclosed to the Plan Administrator solely for the purpose of administering benefits under the Plan.
When Your Health Information May Not Be Used or Disclosed
Except as described in this Notice of Privacy Practices, we will not use or disclose your health information, without written authorization from you or other family members who are provided benefits under the Plan. You may complete and submit the "Authorization for Release of Information" form that permits us to disclose your health information to individuals authorized by you. If you do authorize us to use or disclose your health information for another purpose, you may revoke your authorization in writing at any time. If you revoke your authorization, we will no longer be able to use or disclose health information about you for the reasons covered by your written authorization, though we will be unable to retract any disclosures we have already made with your permission.
Statement of Your Health Information Rights
You have the following rights with respect to your PHI: to request restrictions on certain uses and disclosures of you health information; to receive your health information through a reasonable alternative means or at an alternative location; to request confidential communications; to inspect and cop health information about you that may be used to make decisions about your plan benefits; to request that we amend your health information we keep for the Plan that you believe is incorrect or incomplete; to receive a list or "accounting of disclosures" of your health information made by us, except that we do not have to account for disclosures made for purposes of payment functions or Plan operations, or made to you; to inspect and copy such information; to receive a paper copy of this Notice of Privacy Practices at any time. A request for "accounting of disclosures" must be made in writing and specify a time period of up to six years, and may not include periods before April 14, 2003. One list per 12-month period will be provided free of charge; however, we may charge you for additional lists. If you would like to request restrictions on uses and disclosures of your health information, you must submit your request in writing to the Plan Administrator, or us as third party administrator of Plan claims. We are not required to agree to your request.
If you would like to have a more detailed explanation of these rights or if you would like to exercise one or more of these rights, contact the Plan Administrator or the Privacy Officer of BDG in writing.
Changes to this Notice of Privacy Practices
We reserve the right to amend this Notice of Privacy Practices at any time in the future and to make the new Notice provisions effective for all health information that it maintains, as allowed or required by law We will promptly revise our Notice and distribute it to you whenever we make material changes to the Notice. Until such time, compliance with the current version of this Notice is required.
If you believe that your privacy rights have been violated, you may file a complaint with the Plan Administrator, the Privacy Officer for BDG, or the Office for Civil Rights of the United States Department of Health and Human Services. All complaints must be submitted in writing. You will not be penalized, or in any other way retaliated against, for filing a complaint with the Office for Civil Rights or with us.
Effective Date of this Revised Notice: September 15, 2010.
If you would like an expanded version of this notice contact:
Benefits Design Group, Inc.
P.O. Box 370, Onalaska, WI 54650
1-800-554-7213 or 1-800-342-8235