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BOSTON MUTUAL LIFE INSURANCE COMPANY LIFE INSURANCE COMPANY OF
BOSTON & NEW YORK Health Insurance
Portability and Accountability Act of
1996 (HIPAA) 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. NOTE: The HIPAA requirements regarding Personal Health Information only apply to information which we collect in regard to our dental insurance, student medical insurance and our medical reimbursement expense products. We are required by law to maintain the privacy of Personal Health
Information and to provide you with notice of our legal duties and privacy
practices with respect to Personal Health Information. We are required to abide
by the terms of this Notice so long as it remains in effect. We reserve the right to
change our Privacy practices, procedures, and terms of this HIPAA Notice of
Privacy Practices for Personal health Information(“Notice”) as necessary, and
to make the new Notice effective for all personal health information maintained
by us. If a material change is made to the terms of this Notice, a revised Notice will be provided to all primary
insureds. You may also obtain a copy of the Notice by accessing our website at www.bostonmutual.com or by mailing a
request to the address below. Uses
and Disclosures of Your Personal Health Information Your Authorization Except as outlined below, we will not use or disclose your
Personal Health Information for any purpose unless you have signed a form authorizing the use or disclosure. You have the
right to revoke that authorization in writing.
We will honor your request to revoke as of the day we receive it and to
the extent that we have not already used or disclosed your Personal Health
Information in good faith with the authorization. For Payment We may use and disclose your Personal Health Information as
necessary for payment purposes. For instance, we may use and disclose
information regarding your medical care to process and pay claims. For Health Care Operations We may use and disclose your Personal Health Information as
necessary, and as permitted by law, for our health care operations such as underwriting, customer service, premium
rating, claims, fraud and abuse prevention and detection, and other functions
related to your health policy. We may use and disclose your Personal Health
Information to provide you with information about treatment alternatives or
other benefits and services that may be of interest to you. To Your Personal Representative With your approval, we may disclose your Personal Health
Information to designated family, friends, and others, to assist that person in
caring for you or in paying for your care. If you are unavailable,
incapacitated, or facing an emergency medical situation, and we determine that a limited disclosure
may be in your best interest, we may share limited Personal Health Information with such individuals
without your approval. To Business Associates At times it may be necessary for us to provide some Personal
Health Information to one or more outside persons or organizations who assist us with our business
activities. We require these business associates to appropriately
safeguard the privacy
of your information. Additional Uses and Disclosures Without Your Authorization We are permitted or required by law to make certain other uses and
disclosures of your Personal Health Information without your authorization,
including under the following conditions: ·
for any purpose as required by law; ·
for public health activities, such as required reporting of
certain diseases; ·
as required by law if we suspect child abuse or neglect; ·
we may also release your Personal Health Information as required by law if we believe you to be a victim
of abuse, neglect, or domestic violence; ·
if required by law to a government oversight agency conducting
audits, investigations, or civil or criminal proceedings; ·
if required to do so by a court or administrative ordered
subpoena, discovery request, or qualified protective order; ·
to law enforcement officials as required by law; ·
to coroners and/or funeral directors consistent with law; ·
if necessary to arrange an organ or tissue donation from you or a transplant for you; ·
for certain research purposes when such research is approved by an
institutional review board with established rules to ensure privacy; ·
if you are a member of the military(including veterans) as
required by armed forces services; ·
we may also release your Personal Health Information if necessary
for national security or intelligence activities; ·
when necessary to avert a serious threat to your health or safety
or to the health or safety of another individual or the public; or, ·
to workers compensation agencies and similar programs if necessary
for your workers' compensation benefit determination. Your
HIPAA Privacy Rights Right to Inspect and Copy Your Personal Health Information You have the right to obtain a copy and inspect specific items of
your Personal Health Information, such as your policy or claim information, for as
long as we maintain it. We may deny your request to access certain Personal
Health Information, as permitted or required by law. This includes psychotherapy
notes and information collected by us in connection with, or in reasonable
anticipation of or use in a civil, criminal or administrative action or
proceeding. We may require your request
for access in writing. Your request for access should contain as much detail as
possible regarding the Personal Health Information you wish to review. We may
charge a reasonable fee for access to your Personal Health Information. Amendments to Your Personal Health Information You have the right to request an amendment of the Personal Health
Information we maintain about you if you believe it is incorrect. We are not
legally obligated to make all requested amendments but will give each request
appropriate consideration.
Requests for amendment must be in writing and must state the reasons for the
amendment request. Accounting for Disclosures of Your Personal Health Information You have the right to request a list or accounting of certain
disclosures of your Personal Health Information. We are not legally obligated to
provide an accounting of every disclosure but will give each request
appropriate consideration. Requests must be made in writing. The accounting
will not include disclosures made prior to April 14, 2003. Restrictions on Uses and Disclosures of Your Personal Health
Information You have the right to request restrictions on certain uses and
disclosures of your Personal Health Information for treatment, payment, or
health care operations by notifying us of your request for a restriction in
writing. We are not legally required to
agree to your restriction request. Confidential Communication of Personal Health Information You have the right to request that communications regarding your
Personal Health Information be provided to you at an alternative location or by
alternative means. We will accommodate
any reasonable request if the normal method of disclosure would endanger you
and that danger is stated in your request.
Any such request must be made in writing to the Privacy Officer at the
address shown below. Complaints If you believe your
privacy rights have been violated, you can file a complaint with us or with the
Secretary of the U.S. Department of Health and Human Services in Washington D.C., 200
Independence Ave. SW, Washington, DC 20201.
There will be no retaliation for filing a complaint. All complaints must be submitted in writing.
How to Contact us If you have questions or need further assistance regarding this
Notice, or wish to exercise any of the above-mentioned rights, you may contact the
HIPAA/Privacy Officer at the address below: Privacy Officer
Your State Privacy Rights Your state law may provide additional privacy rights. Effective date This Notice of Privacy Practices is effective April 14, 2003 
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