THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND
DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION
Wickard Insurance understands your medical and health information is personal. Protecting your health information is important. We follow strict federal and state laws that require us to maintain the confidentiality of your health information.
Uses and Disclosures
Treatment: Your health information may be used by staff members or disclosed to other health care professionals or emergency personnel for the purpose of evaluating and providing treatment.
Payment: Your health information may be used to seek payment from other sources to cover such as from credit card companies that you may use to pay for services. For example, your health plan may request and receive information on dates of service, the service provided, and the medical conditions being treated.
Health care operations: Your health information may be used as necessary to support the day-to-day activities and management of Wickard Insurance. For example, information on the services you received may be used to support budgeting and financial reporting, and activities to evaluate and promote quality.
Law Enforcement: Your health information may be disclosed to law enforcement agencies to support government audits and inspections, to facilitate law-enforcement investigations, and to comply with government mandated report.
Public Health Reporting: Your health information may be disclosed to public health agencies as required by law. For example, we are required to report certain communicable diseases to the states public health department.
Other uses and disclosures require your authorization. Disclosure of your health information or its use for any purpose other than those listed above requires your specific written authorization. If you change your mind after authorizing a use or disclosure of your information you may submit a written revocation of the authorization. However, your decision to revoke the authorization will not affect or undo any use or disclosure of information that occurred before you notified us of your decision to revoke your authorization. We may disclose medical information about you to a friend or family member whom you designated on your contact list. We may also disclose your information to disaster relief authorities so that your family can be notified of your location and condition.
Complaints or to Obtain a Copy of your records
If you would like to submit a comment or complaint about our privacy practice, you can do so by sending a letter outlining your concerns to:
PO Box 1326
Delaware, OH. 43015
If you believe that your privacy rights have been violated, you should call the matter to our attention by sending a letter describing the cause of your concern to the same address. You will not be penalized or otherwise retaliated against for filing a complaint.
Authorization and Release
I authorize any physician, health care professional, dentist, health plan, hospital, clinic, laboratory, pharmacy, or other covered health care provider, and insurance company and the Medicaid Information Bureau, Inc., or other health care clearinghouse that is providing or has provided treatment or services to me, or that has paid for or is seeking payment from me for such services, to give, disclose and release without restriction, all of my individually identifiable health information and medical records regarding any past, present, or future medical or mental health condition, including but not limited to all information relating to the diagnosis and treatment of mental illness, and drug alcohol abuse. This authority given shall supersede any prior agreement that I have made with my health care providers to restrict access to or disclose my individually identifiable health information. The authorization contains no expiration date.