Member Privacy Notice

This Notice describes how medical information about you may be used and disclosed by Affinity Health Plan and how you can get access to this information. Please read it carefully.

Why Affinity Health Plan Collects Health Information About You

In order to provide you with the benefits to which you are entitled, Affinity Health Plan must collect, create and maintain health information about you. Affinity Health Plan is required by law to maintain the privacy of this information. This Notice of Privacy Practices describes how Affinity Health Plan uses and discloses your health information, and explains certain rights you have regarding this information. Affinity Health Plan is required by law to provide you with this Notice and we will comply with its terms during the period when it is effective. If you have any questions about our Privacy Policies and Procedures, you may call our toll free number 1-866-247-5678, or write to our Chief Privacy Officer, Affinity Health Plan, 2500 Halsey Street, Bronx, New York 10461.

How Affinity Health Plan Uses and Discloses Your Health Information

The following is a list of the ways in which Affinity Health Plan may use and disclose your health information. We will use and disclose your health information only for one of the purposes on this list. In certain cases, we provide examples of the types of uses or disclosures that fall within a particular category. These examples are intended to help you understand what these categories mean; they do not cover every type of use or disclosure within each category. Please note that, as discussed later in this Notice of Privacy Practices, special rules apply to our disclosure of certain alcohol and drug abuse treatment records.

Uses and Disclosures for Payment and Health Care Operations. After Affinity Health Plan has obtained your general consent to use and disclose your health information to administer your benefits and for other purposes permitted by state or federal law, we may use and disclose your health information for the following purposes.

• Treatment. We may use and disclose health information about you to facilitate treatment by health care providers. For example, if one of our participating health care providers is treating you, we may disclose to this provider health information relating to other health care services you have received that may be relevant to the provider’s treatment.

• Payment. We may use and disclose health information about you for our own payment purposes and to assist in the payment activities of other health plans and health care providers. Our payment activities include collecting premiums, determining your eligibility for benefits, reimbursing health care providers that treat you and obtaining payment from other insurers that may be responsible for providing coverage to you. For example, if a health care provider submits a bill to us for services you received, we may use health information about you to determine whether these services are covered under your benefit plan and the appropriate amount of payment to which the provider may be entitled.

• Health Care Operations. We may use and disclose health information about you to carry out health care operations, which includes quality improvement activities, evaluating our own performance and resolving any complaints or grievances you may have. For example, we may collect and review records maintained by doctors and hospitals that have treated you to see whether they have provided you with preventive treatment and other important health services that are recommended by medical authorities. We may also use and disclose your health information to assist other health plans and health care providers in performing certain health care operations, such as quality assessment and improvement, reviewing the competence and qualifications of health care providers and conducting fraud detection or compliance.

• Appointment Reminders. We may use and disclose your health information to remind you about appointments you have made to receive health care services or to encourage you to make such appointments.

• Treatment Alternatives. We may use and disclose your health information to tell you about treatment alternatives or other health-related benefits and services that may be of interest to you.

Uses and Disclosures Without Your Consent or Authorization. Affinity Health Plan may use and disclose your health information without your specific written authorization for the following purposes:

• As required by law. We may use and disclose your health information as required by state, federal or local law.

• For public health activities. We may disclose your health information to public health authorities or other agencies and organizations conducting public health activities, such as preventing or controlling disease, injury or disability and reporting births, deaths, child abuse or neglect, domestic violence, potential problems with products regulated by the Food and Drug Administration or communicable diseases.

• About victims of abuse, neglect or domestic violence. We may disclose your health information to an appropriate government agency if we believe you are a victim of abuse, neglect or domestic violence and you agree to the disclosure or the disclosure is required or permitted by law. We will let you know if we disclose your health information for this purpose unless we believe that letting you know would place you at risk of serious harm or we believe that a person who usually receives information from us on your behalf is responsible for the abuse, neglect or domestic violence.

• For health oversight activities. We may disclose your health information to health oversight agencies for oversight activities authorized by law such as audits, investigations, inspections and licensing surveys.

• For judicial and administrative proceedings. We may disclose your health information in the course of any judicial or administrative proceeding in response to an appropriate order of a court or administrative body.

• For law enforcement purposes. We may disclose your health information to a law enforcement official for a legitimate law enforcement purpose such as: identifying or locating a suspect, fugitive or missing person; complying with a court order, subpoena or administrative request; providing information about a victim of a crime or reporting a death that may be the result of a crime.

• About deceased individuals. We may disclose your health information to a coroner or medical examiner for purposes such as identifying a deceased person or determining a cause of death. We may also disclose your health information to a funeral director as necessary to assist such a person in carrying out his or her duties.

• For organ, eye or tissue donations. We may disclose your health information to organ procurement organizations and similar entities for the purpose of assisting them in organ, eye or tissue donation or transplantation activities, in the event that you need one for your treatment.

• For research. We may use or disclose your health information for research purposes, such as studies comparing the benefits of alternative treatments received by our members or investigations into how to improve our enrollment and education procedures. We will use or disclose your health information for research purposes only with the approval of our privacy board, which must follow a special approval process. Before permitting any use or disclosure of your health information for research purposes, our privacy board will balance the needs of the researchers and the potential value of their research against the protection of your privacy.

• To avert a serious threat to health or safety. We may use or disclose your health information to prevent or lessen a serious and immediate threat to your health or safety or to the health or safety of another person or the general public. We will disclose your health information for this purpose only to someone who may be able to prevent or lessen this type of threat.

• For specialized government functions. We may use or disclose your health information to provide assistance for certain types of government activities. If you are a member of the armed forces of the United States or a foreign country, we may disclose your health information to appropriate military authorities as they deem necessary to carry out military missions. We may also disclose your health information to federal officials for lawful intelligence or national security activities and for the purpose of providing protective services to the President of the United States and other officials. In addition, if you are in the custody of a correctional institution or law enforcement official, we may disclose your health information to that institution or official for certain purposes.

• For workers’ compensation. We may use or disclose your health information as permitted by the laws governing the workers’ compensation program or similar programs that provide benefits for work-related injuries or illnesses.

• To individuals involved in your care. We may disclose your health information to a family member, other relative or close personal friend assisting you in receiving or obtaining payment for health care services. We will disclose your health information to these individuals only if you tell us to do this or if we advise you that we will do so and you do not object. We may also disclose your health information to disaster relief organizations such as the Red Cross to assist your family members or friends in locating you or learning about your general condition in the event of a disaster.

Special Treatment of Certain Alcohol and Drug Abuse Records. Health information we may receive about you from federally assisted alcohol or drug treatment programs is subject to special protection under federal law. We will not disclose this information without your express written authorization except:

• to medical personnel who need this information for the purpose of providing you with emergency treatment;

• to the Food and Drug Administration for the purpose of identifying potentially dangerous products;

• for research purposes if approved by our privacy board;

• to authorized persons conducting on-site audits of our records, subject to the requirement that these persons not remove the information from our facilities and agree in writing to safeguard the information; and

• in response to an appropriate court order.

Obtaining Your Authorization for Other Uses and Disclosures. Affinity Health Plan will not use or disclose your health information for any purpose not specified in this Notice of Privacy Practices unless we obtain your express written authorization. If you give us your authorization, you may revoke it at any time, in which case we will no longer use or disclose your health information for the purpose you authorized, except to the extent we have relied on your authorization in providing benefits. The authorization you give for these uses and disclosures is different from the general consent form you sign at the time of enrollment in Affinity Health Plan. While the consent form contains general language allowing us to use and disclose your health information for treatment, payment, health care operations and other purposes permitted by law, the authorization form more specifically describes the purpose of the use or disclosure, the nature of the information that will be used or disclosed and the persons or groups of persons to whom the information will be made available. In addition, while you are required to sign a consent form in order to receive benefits from us, we may not refuse to enroll or continue to provide benefits to you if you decide not to sign an authorization form.

Your Rights Regarding Your Health Information

You have the following rights regarding your health information:

Right to Inspect and Copy. You have the right to inspect or request a copy of health information about you that we maintain and that we may use in making decisions about your benefits. Your request should describe the information you want to review and the format in which you want to review it; for example, whether you want to inspect your records at our offices, receive paper copies or get the information on a computer diskette. We may refuse to allow you to inspect or obtain copies of this information in certain limited cases. We may charge you a reasonable fee for copies to cover our costs. You may ask to inspect or obtain copies of your information by writing to our Chief Privacy Officer or our Director of Member Services, Affinity Health Plan, 2500 Halsey Street, Bronx, New York 10461.

Right to Request Amendments. You have the right to request changes to any health information we maintain about you if you state a reason why this information is incorrect or incomplete. We do not have to agree to make the changes you request. If we do not believe the changes you requested are appropriate, we will notify you in writing how you can have your objection to our decision included in our records. You may request changes to your health information by writing to our Chief Privacy Officer or our Director of Member Services.

Right to an Accounting of Disclosures. You have the right to receive a list of disclosures of your health information that have been made by Affinity Health Plan. The list will not include disclosures made for certain types of purposes, such as disclosures for treatment, payment or health care operations or disclosures you authorized in writing. Your request should specify the time period for which you want this list, which can be no longer than six years and may not include dates prior to April 14, 2003. The first time you ask for a list of disclosures in any 12-month period, we will provide it for free. If you request additional lists during a 12-month period, we may charge you a fee to cover our costs in providing the additional lists. You may request a list of disclosures by writing to our Chief Privacy Officer or our Director of Member Services.

Right to Request Restrictions. You have the right to request restrictions on the ways in which we use and disclose your health information for treatment, payment and health care operations, or disclose this information to disaster relief organizations or individuals who are involved in your care. We do not have to agree to the restrictions you request. You may request a restriction on the use or disclosure of your health information by writing to our Chief Privacy Officer or our Director of Member Services.

Right to Request Confidential Communications. You have the right to ask us to send health information to you in a different way or at a different location if you believe that you may be endangered by our ordinary form of communication. For example, if you are afraid that someone living with you may open mail we send you and harm you as a result, you can ask us to send your mail to a relative’s or employer’s address. You must state in your request that you believe you will be endangered by our ordinary form of communication but you do not have to explain why you believe this is the case. Your request should also specify where and/or how we should contact you. We will accommodate all reasonable requests. You may ask us to send health information to you in a different way or at a different location by writing to our Chief Privacy Officer or our Director of Member Services.

Right to Paper Copy of Notice. You have the right to receive a paper copy of this Notice of Privacy Practices at any time. You may receive a paper copy even if you have previously requested to receive this Notice electronically. You may obtain a paper copy of this Notice, by writing to our Chief Privacy Officer or our Director of Member Services. You may also print out a copy of this Notice by going to our website at www.affinityplan.org .

Right to File a Complaint. If you believe your privacy rights have been violated, you may file a complaint with Affinity Health Plan or the Secretary of the U.S. Department of Health and Human Services. You may file a complaint with Affinity Health Plan by writing to our Chief Privacy Officer or our Director of Member Services Affinity Health Plan, One Fordham Plaza, Bronx, New York, 10458. We will not penalize or retaliate against you for filing a complaint.

Changes to this Notice. Affinity Health Plan may change the terms of this Notice of Privacy Practices at any time. If we change the terms of this Notice, the new terms will apply to all of your health information, whether created or received by us before or after the date on which the Notice is changed. We will notify you of changes to this Notice by mailing you a copy of the new Notice within 60 days of the date on which it becomes effective.

Additional Information. If you have any questions or would like additional information about this Notice or our privacy practices, please contact our Chief Privacy Officer or our Director of Member Services, Affinity Health Plan, 2500 Halsey Street, Bronx, New York 10461. Tel: 1-866-247-5678.

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2500 Halsey Street, Bronx, NY 10461 | Phone 718-794-7700 | Fax 718-794-7800