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 following organizations within the ULLICO Family of Companies use health information about you for payment, health care operations, and administrative purposes.
We are required by applicable federal and state law to maintain the privacy of your protected health information. "Protected health information" is information that is created or received by us that reasonably identifies you, and relates to your past, present or future physical or mental condition, or the past, present or future provision for, or payment of, health care for you. We are also required to give you this notice of our privacy practices, our legal duties, and your rights concerning your protected health information. We must follow the privacy practices described in this notice while it is in effect. This notice is effective as of April 14, 2003, and will remain in effect until we replace it.
We reserve the right to change our privacy practices and this notice at any time, provided the changes are permitted by law. We reserve the right to make changes effective for all protected health information we maintain, including information that we created or received before we made the changes. We will send a revised notice to you before we make significant changes to our privacy practices.
You may request a copy of our notice at any time. For more information about our privacy practices, or for additional copies of this notice, please contact us using the information listed at the end of this notice.
We may use and disclose protected health information about you for payment and health care operations. For example:
Payment: We may use or disclose your protected health information to pay claims from physicians, hospitals and other providers for services delivered to you that are covered by your health plan or policy, to determine your eligibility for benefits, to coordinate your health benefits with other insurers or providers, to examine the medical necessity for services given or offered to you, to obtain premiums, or to issue you an explanation of your benefits under your health plan. We may also disclose your protected health information to health care providers or other entities so they may obtain payment or engage in any of these payment activities.
Health Care Operations: We may use and disclose your protected health information in connection with our health care operations, which includes the following:
We may also disclose your protected health information to another entity that has a relationship with you for its health care operations, as described above.
We may use your protected health information to contact you with information about health-related benefits and services, or treatment alternatives, which may be of interest to you. We may also disclose your protected health information to a business associate to assist in these activities, provided that our business associate also agrees to protect your rights to the privacy of that information. Our business associates are outside persons or entities with which we have a contractual arrangement to assist us in the performance of certain aspects or components of our services. Examples of our business associates include agents, brokers, re-insurers, third party administrators, medical management services, collection agencies and attorneys.
To Your Family and Friends: We may disclose your protected health information to a family member, close personal friend or other person identified by you, as necessary to help with your health care or with payment for your health care. Before we disclose your protected health information to such a person, we will contact you so you can agree or object to the disclosure. If we cannot contact you, such as in the event of your incapacity or an emergency, we will use our professional judgment to decide whether the disclosure would be in your best interest, subject to any applicable laws.
Your Employer or Organization Sponsoring Your Health Plan: If you are a member of a group health plan, we may disclose your protected health information to the employer or other organization that sponsors your group health plan, to permit the plan sponsor to perform plan administration functions.
On Your Authorization: You may give us written authorization to disclose your protected health information to any person or entity, for any purpose. You may also revoke your authorization at any time, in writing, but your revocation will not affect any previous uses or disclosures that were made while your authorization was in effect. We cannot use or disclose your protected health information except as described in this notice, unless you give us written authorization to do so.
Uses or Disclosures for which Consent or Authorization is Not Required: We may use or disclose your protected health information as authorized by law for the following purposes deemed to be in the public interest or benefit:
Access: You have the right to examine or receive copies of your protected health information, with limited exceptions. If we deny your request, we will explain the reason for the denial and provide you with information on how to appeal the decision. You may also request that we provide the copies in any format and we will accommodate your request unless we cannot practicably do so. You must make your request, in writing, by using a standard form that you may obtain from the contact office at the end of this notice. If you request photocopies and ask that they be sent by mail, we will charge you a cost-based fee and postage. You may contact us using the information at the end of this notice for an explanation of our fee structure.
Disclosure Accounting: You have the right to receive a list of instances in which we, or our business associates, disclosed your protected health information for purposes other than treatment, payment or healthcare operations, as authorized by you, and for certain other activities, since April 14, 2003. We will provide you the date on which we made the disclosure, the name of the entity or person to whom we disclosed your protected health information, a description of the information, and the reason for the disclosure. If you request more than one accounting in a twelve month period, we may charge you a cost-based fee for responding to additional requests. You may contact us using the information at the end of this notice for an explanation of our fee structure.
Restriction: You have the right to request that we place additional restrictions on our use or disclosure of your protected health information. We are not required to agree to additional restrictions, but if we do so, we will abide by our agreement unless we are prevented from doing so, such as in the case of an emergency. An agreement to abide by additional restrictions must be in writing and must be signed by a person authorized to make such a decision on our behalf.
Confidential Communication: You have the right to request us to communicate with you about your protected health information by alternate means or to alternate locations. You must make your request in writing, and must state that the protected health information could endanger you if it is not communicated to you in confidence. We must accommodate your request, if it is reasonable, it specifies the alternate means or locations, and it continues to permit us to collect our premiums and pay claims under your health plan, including the issuance of explanations of benefits to the contract holder of the health plan in which you participate.
Amendment: You have the right to request that we amend your protected health information. Your request must be in writing, and it must explain why the information should be amended. We may deny your request if we did not create the information and the originator remains available to do so, or for other reasons. If we deny your request, we will provide you a written explanation of our decision. You may respond with a written statement of disagreement that will be attached to the information that you requested to be amended. If we agree with your request to amend the information, we will make reasonable efforts to inform others and to include the changes in any future disclosures of that information.
Electronic Notice: If you receive this notice on our web site or by electronic mail (email), you are entitled to receive a written copy, if you request one. Please contact us using the information at the end of this notice to obtain a written copy of this notice.
If you want more information about our privacy practices or have questions or concerns, please contact us using the information listed at the end of this notice.
If you are concerned that we may have violated your privacy rights, or you disagree with a decision we made about your protected health information, you may complain to us using the contact information listed at the end of this notice. You may also submit a written complaint to the U.S. Department of Health and Human Services. We will provide the address to file your complaint to the U.S. Department of Health and Human Services upon your request.
We support your right to the privacy of your health information. We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services.
Contact Office
Mailing Address:
ULLICO Inc.
1625 Eye Street, N.W.
Washington, D.C. 20006
Attn: Privacy Officer
Telephone: 1-800-431-5425