Individual privacy rights
NOTE: Arnett Evans & Company is contracted with multiple insurance carriers that provide separate and different insurance policies. It is important to us that you get as much information as possible when it involves your healthcare and your rights. This document should not be considered absolute, but rather a guide to some of the rights you may be entitled to. Please refer to your personal insurance carrier's privacy right document to know your rights as it pertains to your insurance company, federal, and state laws; as well as, and what each entity does with your information. This documentation is aligned to only one particular company with which we have had a long-standing relationship and have adopted this document into our practices. View our Privacy Policy here.
Individual rights forms
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 privacy of your personal and health information is important. You don’t need to do anything unless you have a request or complaint.
We may change our privacy practices and the terms of this notice at any time, as allowed by law. Including information, we created or received before we made the changes. When we make a significant change in our privacy practices, we will change this notice and send the notice to our health plan subscribers. What is personal and health information? Personal and health information includes both medical information and personal information, like your name, address, telephone number, or Social Security number. The term “information” in this notice includes any personal and health information. This includes information created or received by a healthcare provider or health plan. The information relates to your physical or mental health or condition, providing healthcare to you, or the payment for such healthcare. How do we protect your information? We have a responsibility to protect the privacy of your information in all formats including electronic, written, and oral information. We have safeguards in place to protect your information in various ways including:
Limiting who may see your information
Limiting how we use or disclose your information
Informing you of our legal duties regarding your information
Training our employees about our privacy program and procedures
How do we use and disclose your information?
We use and disclose your information:
To you or someone who has the legal right to act on your behalf
To the Secretary of the Department of Health and Human Services
We have the right to use and disclose your information:
To a doctor, a hospital, or other healthcare provider so you can receive medical care.
For payment activities, including claims payment for covered services provided to you by healthcare providers and for health plan premium payments.
For healthcare operation activities. Including processing your enrollment, responding to your inquiries, coordinating your care, improving quality, and determining premiums.
For performing underwriting activities. However, we will not use any results of genetic testing or ask questions regarding family history.
To your plan sponsor to permit them to perform, plan administration functions such as eligibility, enrollment, and disenrollment activities. We may share summary-level health information about you with your plan sponsor in certain situations. For example, to allow your plan sponsor to obtain bids from other health plans. Your detailed health information will not be shared with your plan sponsor. We will ask your permission or your plan sponsor has to certify they agree to maintain the privacy of your information.
To contact you with information about health-related benefits and services, appointment reminders, or treatment alternatives that may be of interest to you. If you have opted out as described below, we will not contact you.
To your family and friends if you are unavailable to communicate, such as in an emergency.
To your family and friends, or any other person you identify. This applies if the information is directly relevant to their involvement with your health care or payment for that care. For example, if a family member or a caregiver calls us with prior knowledge of a claim, we may confirm if the claim has been received and paid.
To provide payment information to the subscriber for Internal Revenue Service substantiation
To public health agencies, if we believe that there is a serious health or safety threat
To appropriate authorities when there are issues about abuse, neglect, or domestic violence
In response to a court or administrative order, subpoena, discovery request, or other lawful process
For law enforcement purposes, to military authorities, and as otherwise required by law
To help with disaster relief efforts
For compliance programs and health oversight activities
To fulfill our obligations under any workers’ compensation law or contract
To avert a serious and imminent threat to your health or safety or the health or safety of others
For research purposes in limited circumstances
For procurement, banking, or transplantation of organs, eyes, or tissue
To a coroner, medical examiner, or funeral director
Will we use your information for purposes not described in this notice?
We will not use or disclose your information for any reason that is not described in this notice, without your written permission. You may cancel your permission at any time by notifying us in writing. The following uses and disclosures will require your written permission:
Most uses and disclosures of psychotherapy notes
Marketing purposes
Sale of personal and health information
What do we do with your information when you are no longer a member?
Your information may continue to be used for purposes described in this notice. This includes when you do not obtain coverage through us. After the required legal retention period, we destroy the information following strict procedures to maintain confidentiality.
What are my rights concerning my information?
We are committed to responding to your rights request promptly
Access – You have the right to review and obtain a copy of your information that may be used to make decisions about you. You also may receive a summary of this health information. If you request copies, we may charge you a fee for the labor for copying, supplies for creating the copy (paper or electronic), and postage.
Adverse Underwriting Decision – If we decline your insurance application, you have the right to be provided a reason for the denial.
Alternate Communications – To avoid a life-threatening situation, you have the right to receive your information in a different manner or at a different place. We will accommodate your request if it is reasonable.
Amendment – You have the right to request correction of any of this personal information through amendment or deletion. Within 30 business days of receipt of your written request, we will notify you of our amendment or deletion of the information in dispute, or of our refusal to make such correction after further investigation. If we refuse to amend or delete the information in dispute, you have the right to submit to us a written statement of the reasons for your disagreement with our assessment of the information in dispute and what you consider to be the correct information. We shall make such a statement accessible to any parties reviewing the information in dispute.*
Disclosure – You have the right to receive a listing of instances in which we or our business associates have disclosed your information. This does not apply to treatment, payment, health plan operations, and certain other activities. We maintain this information and make it available to you for six years. If you request this list more than once in 12 months, we may charge you a reasonable, cost-based fee.
Notice – You have the right to request and receive a written copy of this notice at any time.
Restriction – You have the right to ask to limit how your information is used or disclosed. We are not required to agree to the limit, but if we do, we will abide by our agreement. You also have the right to agree to or terminate a previously submitted limitation.
What types of communications can I opt out of that are made to me?
Appointment reminders
Treatment alternatives or other health-related benefits or services
Fundraising activities