Page 1 Page 2 Page 3 Page 4 Page 5 Page 6 Page 7 Page 8 Page 9 Page 10 Page 11 Page 12 Page 13 Page 14 Page 15 Page 16 Page 17 Page 18 Page 19 Page 20 Page 21 Page 22 Page 23 Page 24 Page 25 Page 26 Page 27 Page 28 Page 29 Page 30 Page 31 Page 32 Page 33 Page 34 Page 35 Page 36 Page 37 Page 38 Page 39 Page 40 Page 41 Page 42 Page 43 Page 4437 HIPAA Individual Rights (cont’d) chosen by us will review your request and the denial. The person performing this review will not be the same person who denied your initial request. Disclosure Accounting: You have the right to receive a list of instances in which we or our business associates disclosed your protected health information, including a disclosure involving an electronic health record, for purposes other than treatment, payment, health care operations and certain other activities (Note: this exemption does not apply to electronic health records). We will provide you with the date on which we made the disclosure, the name of the person or entity to which we disclosed your protected health information, a description of the protected health information we disclosed, the reason for the disclosure, and cer- tain other information. If you request this list more than once in a 12-month period, we might charge you a reasonable, cost-based fee for responding to these additional requests. You may request an accounting by submitting your request in writing using the information listed at the end of this notice. Your request may be for disclosures made up to 6 years before the date of your request (three years in the case of a disclosure involving an electronic health record). Restriction Requests: 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 these addi- tional restrictions, but if we do, we will abide by our agreement (except in an emergency). Any agreement that we might make to a request for additional restrictions must be in writing and signed by a person authorized to make such an agreement on our behalf. We will not be liable for uses and disclosures made outside of the requested restriction unless our agreement to restrict is in writing. We are permitted to end our agreement to the requested restric- tion by notifying you in writing. You may request a restriction by writing to us using the information listed at the end of this notice. In your request tell us: (1) the information of which you want to limit our use and disclosure; and (2) how you want to limit our use and/or disclosure of the information. Confidential Communication: If you believe that a disclosure of all or part of your protected health information may endanger you, you have the right to request that we communicate with you in confidence about your protected health information. This means that you may request that we send you information by alternative means, or to an alternate location. We must accom- modate your request if: it is reasonable, specifies the alternative means or alternate location, and specifies how payment issues (premiums and claims) will be handled. You may request a Con- fidential Communication by writing to us using the information listed at the end of this notice. 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 informa- tion should be amended. We may deny your request if we did not create the information you want amended or for certain other reasons. If we deny your request, we will provide you with a writ- ten explanation. You may respond with a statement of disagree- ment to be appended to the information you wanted amended. If we accept your request to amend the information, we will make reasonable efforts to inform others, including people you name, of the amendment and to include the changes in any future disclo- sures of that information. Electronic Notice: This notice is also posted on our web site. Questions and Complaints Information WSSC’s Privacy Practices: If you want more information about our privacy practices or have questions or concerns, please contact the member services number on the back of your card. Filing a Complaint: If you are concerned that we might have violated your privacy rights, or you disagree with a decision we made about your individual rights, you may use the contact information listed at the end of this notice to complain to us. You also may submit a written complaint to the U.S. Department of Health and Human Services (DHHS). We will provide you with the contact information for DHHS upon request. We support your right to protect the privacy of your protected health and financial informa- tion. 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. HIPAA website: WSSC Privacy Official: Carole C. Silberhorn Human Resources Manager – Benefits 14501 Sweitzer Lane Laurel, MD 20707-5902 Phone: 301-206-8691 Fax: 301-206-8713 Email: Alternate Email: