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Privacy Policy for
NH Local Government Center (LGC)
HealthTrust, Inc.

The following 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.

Purpose and Effective Date of This Notice
Uses and Disclosures of Protected Health Information
Special Situations for Disclosure of Protected Health Information
Your Rights Regarding Your Protected Health Information
Conclusion

Purpose and Effective Date of This Notice
The LGC HealthTrust is required by law to maintain the privacy of your personal health information and to give you this Notice of our privacy practices, our legal duties and your rights with respect to your protected health information. The term "protected health information" means any information relating to your health or health care which identifies you and is transmitted or maintained by LGC HealthTrust in any form (oral, written or electronic). This Notice does not apply to information that has been "de-identified." Health information is considered "de-identified" if it does not identify an individual and there is no reasonable basis to believe that the information can be used to identify an individual.

Effective Date: This Notice, effective April 14, 2003, will remain in effect until it is replaced or changed. The LGC HealthTrust is required to comply with the terms of this Notice as long as it is in effect. The LGC HealthTrust reserves the right to change its privacy practices as described in this Notice and to make corresponding changes to this Notice at any time. Any such change will apply to all protected information we already have about you and any such information we receive in the future. If there is any material change in LGC HealthTrust’s privacy practices as described herein, the Notice will be revised and the new Notice will be distributed to covered subscribers and available to anyone upon request. The LGC HealthTrust will post any changes and the current version of the Notice on our website at http://www.nhlgc.org. You may request a copy of this Notice at any time.

Contact: If you have any questions or need further information regarding this Notice, or if you wish to receive another copy, please contact:

Privacy Officer
LGC HealthTrust, Inc.
PO Box 617
Concord, NH 03302-0617
800.527.5001

Uses and Disclosures of Protected Health Information
The LGC HealthTrust contracts with business associates who assist us in the administration of your medical and/or dental plan. The LGC HealthTrust discloses protected health information to its business associates and allows them to create or receive protected health information on our behalf. As a condition of sharing protected health information with a business associate, the LGC HealthTrust obtains written assurance that the business associate will appropriately safeguard the information in a manner that complies with this Notice and applicable federal privacy regulations. The LGC HealthTrust and its business associates may use and disclose your protected health information, without your authorization or opportunity to object, for purposes of treatment, payment and healthcare operations and as otherwise required or permitted by law. For example: Treatment: A business associate acting on our behalf (such as our claims administrator) may use or disclose your protected health information to a physician or other health care provider who is providing treatment to you for the purpose of coordinating the provision of your healthcare coverage. Payment: Your protected health information may be used or disclosed to make coverage determinations and proper payment for covered services under your medical or dental plan, including such activities as billing, transmission of eligibility and enrollment information, subrogation and review of claims appeals. For example, we may verify your eligibility for coverage to our claims administrator or your doctor or dentist. Health Care Operations: We may use or disclose your protected health information in connection with the administration of your medical or dental plan, including such operations as enrollment and eligibility, claims processing, disease management, case management, underwriting, premium rating, legal and auditing services, coordination of benefits, health promotion or wellness programs, and other general business and administrative activities. Disclosures Required by Law: The LGC HealthTrust may use or disclose your protected health information when we are required to do so by law. For example, your protected health information may be disclosed to comply with a court order, an administrative order, a subpoena, a discovery request or for other law enforcement purposes, or to a public health oversight agency for authorized oversight activities. Disclosure of your protected health information also may be required by the U.S. Department of Health and Human Services to investigate or determine LGC HealthTrust’s compliance with the federal privacy regulations. Other Uses and Disclosures Only as Authorized: Any use or disclosure of your protected health information for any purpose other than treatment, payment or health care operations or as required by law will be made only in compliance with your written authorization. You may revoke any such authorization in writing. The LGC HealthTrust does not use or disclose your protected health information for marketing purposes nor does it sell your information for any purpose. Please use LGC HealthTrust's Authorization to Release Information to My Representative form when you want LGC HealthTrust, your group's Benefits Administrator or a family member to work on your behalf for any claims issues.

Minimum Necessary Standard: When using or disclosing protected health information, LGC HealthTrust will make reasonable efforts not to use, disclose or request more than the minimum amount of protected health information necessary to accomplish the intended purpose of the use, disclosure or request, taking into consideration practical and technological limitations. However, the minimum necessary standard will not apply to the following situations:

Special Situations for Disclosure of Protected Health Information
Disclosure to Health Plan Sponsor: Your protected health information generally will not be disclosed to your employer without your written authorization and then only for the purpose of administering benefits under your group medical or dental plan or such other purpose specified in your authorization. However, LGC HealthTrust may disclose to your employer (i) summary health information for use in obtaining premium bids for group health insurance coverage or in connection with modifying, amending or terminating your employer’s health plan; and (ii) information concerning whether you are participating in LGC HealthTrust coverage or you are enrolled with or dis-enrolled from our coverage. For purposes of (i) above, "summary health information" is information which summarizes claims history or experience of individuals in your employer’s health plan which has been de-identified in accordance with the federal privacy regulations.

In addition, LGC HealthTrust may disclose protected health information to your employer, without your authorization, upon receipt of a certification from the employer that it has implemented a policy and has made required amendments to plan documents which ensure that the employer will not use or further disclose protected health information other than as permitted or required by the employer’s policy or as required by law, and in either case only in accordance with the federal privacy regulations. For example, if your employer has a self-funded plan arrangement with LGC HealthTrust and has provided an appropriate certification, we may disclose reports that contain protected health information to the employer for the purpose of administering your plan.

Workers' Compensation: The LGC HealthTrust may disclose your protected health information as authorized by and to the extent necessary to comply with Workers' Compensation or other similar programs that provide benefits for work related injuries or illness without regard to fault.

Your Rights Regarding Your Protected Health Information
You have the following rights regarding the protected health information that we maintain about you: Right to Inspect and Copy: You have the right to inspect and obtain a copy of certain of your protected health information that LGC HealthTrust maintains or that is maintained on our behalf by our business associates. Requests to inspect or copy designated protected health information should be made in writing to the Privacy Officer at the address given above. You or your personal representative will be required to complete a specific form to request such information. If you request a copy of any information, we may charge a fee for the costs of copying, mailing or other supplies needed to fulfill your request. In certain situations the requested protected health information may need to be obtained directly from one of our business associates. The LGC HealthTrust Privacy Officer will advise you regarding the proper procedures in those situations. The requested information will be provided within 30 days if the information is maintained on site or within sixty (60) days if the information is maintained off site. A single 30-day extension is allowed if LGC HealthTrust is unable to comply with the deadline. If access is denied for any or all of the requested protected health information, you or your personal representative will be provided with a written denial setting forth the basis for the denial, a description of any appeal rights, and a description of how you may file a complaint with LGC HealthTrust or the U.S. Department of Health and Human Services. Right to Amend: If you feel your protected health information maintained by LGC HealthTrust is incorrect or incomplete, you may ask to amend the information by contacting the Privacy Officer at the address listed above. Your request for amendment must be in writing on a form provided by LGC HealthTrust. You must provide a reason to support the requested amendment. You may request an amendment for as long as the information is maintained by LGC HealthTrust. Your request may by denied if you request to amend information that:

The LGC HealthTrust has (60 days to act on the request. A single 30-day extension is allowed if LGC HealthTrust is unable to comply with the deadline. If your request is denied in whole or part, LGC HealthTrust will provide you with a written denial setting forth the basis for the denial. You or your personal representative may then submit a written statement disagreeing with the denial and have that statement included with any future disclosures of your protected health information.

Right to an Accounting of Disclosures: You have the right to request and receive an accounting of disclosures by LGC HealthTrust of your protected health information during the six years prior to the date of your request. However, such accounting need not include disclosures made (i) for treatment, payment and healthcare operations; (ii) to you or based on your written authorization; (iii) incident to an otherwise permitted or required use or disclosure; or (iv) that occurred prior to April 14, 2003. You may request an accounting of disclosures by contacting the Privacy Officer at the address listed above. You or your personal representative will be required to complete a form for such request which states a time period which may not be longer than six years and may not include dates prior to April 14, 2003. If the accounting cannot be provided within 60 days, an additional 30 days is allowed provided you are given a written statement of the reasons for the delay and the date by which the accounting will be provided. If you request more than one accounting within a 12-month period, LGC HealthTrust will charge a reasonable, cost-based fee for each subsequent accounting.

Right to Request Restrictions: You may request that LGC HealthTrust restrict the uses and disclosures of your protected health information for treatment, payment or healthcare operations, or to restrict uses and disclosures to family members, relatives, friends or others identified by you who are involved in your care or payment for your care. However, we are not required to agree to your request. Your request to limit or restrict use of your protected health information must be made in writing to the Privacy Officer at the address listed above and the request must include the information you wish to limit, whether you wish to limit use, disclosure or both and to whom the limits may apply, for example, disclosures to your spouse.

Right to Request Confidential Communications: You have the right to request that we communicate with you concerning your protected health information only in certain ways or at certain locations. For example, you may request that we only contact you at work or by mail. Any such request must be made in writing to the Privacy Officer at the address listed above. Where possible, we will accommodate all reasonable requests.

Right to a Paper Copy of This Notice: Even if you have received this Notice electronically, you are entitled to receive a paper copy of this Notice. To request a paper copy, please contact the Privacy Officer at the address or telephone number above.

Right and How to File a Complaint: If you believe your privacy rights have been violated by LGC HealthTrust, you may file a written complaint addressed to the Privacy Officer, LGC HealthTrust, PO Box 617, Concord, NH 03302-0617. The complaint must be in writing. You may also file a written complaint with the Secretary of the U.S. Department of Health and Human Services. You will not be penalized or retaliated against for filing a complaint.

Right to Use a Personal Representative: You may exercise your rights described in this Notice through a personal representative. Your personal representative will be required to produce evidence of his or her authority to act on your behalf before that person will be given access to your protected health information or allowed to take any action for you.

Conclusion
Use and disclosure of protected health information by LGC HealthTrust and its business associates is regulated by a federal law known as HIPAA (the Health Insurance Portability and Accountability Act of 1996) and privacy regulations issued there under. This Notice attempts to summarize our duties and your rights as set forth in those privacy regulations. The regulations will supercede any discrepancy between the information in this Notice and the regulations.