NATIONWIDE LIFE HIPAA NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW PROTECTED HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

The terms of this Notice of Privacy Practices apply to Nationwide; for purposes of this policy, “Nationwide” or “We” means the health plan components of Nationwide Life Insurance Company (“Nationwide Life”), which is a hybrid covered entity and for which Nationwide Health Plans (“NHP”), which is a business associate of the Nationwide Life health insurance products. As permitted by law, Nationwide will share protected health information of members as necessary to cary out treatment, payment, and health care operations.

We are required by HIPAA and certain state laws to maintain the privacy of our members’ protected health information and to provide members with notice of our legal duties and privacy practices with respect to your protected 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 the terms of this Notice of Privacy Practices as necessary and to make the new Notice effective for all protected health information maintained by us. Copies of the revised notices will be mailed to all current plan members or insureds and copies may be obtained by mailing a request to your designated contact point under the Contact Information section, below.

Protected health information that is the subject of this Notice is information that is created or received by Nationwide; and relates to the past, present, or future physical or mental health or condition of a member; the provision of health care to a member; or the past, present, or future payment for the provision of health care to a member or for which there is a reasonable basis to believe the information can be used to identify the member. Protected health information includes information of persons living or deceased. The following components of a member’s information also are considered protected health information:

a) names;
b) street address, city, county, precinct, zip code;
c) dated directly related to a member, including birth date, admission date, discharge date, and date of death;
d) telephone numbers, fax numbers, and electronic maid addresses;
e) Social Security numbers;
f) medical record numbers;
g) health plan beneficiary numbers;
h) account numbers;
i) certificate/license numbers;
j) vehicle identifiers and serial numbers, including license plate numbers;
k) device identifiers and serial numbers;
l) Web Universal Resource Locators (URLs);
m) biometric identifiers, including finger and voice prints;
n) full face photographic images and any comparable images; and
o) any other unique identifying number, characteristic, or code.

USES AND DISCLOSURES OF YOUR PROTECTED HEALTH INFORMATION

Your Authorization. Except as outlined below, we will not use or disclose your protected 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, unless we have taken any action in reliance on the authorization.

Disclosures for Treatment. We will make disclosures of your protected health information as necessary for your treatment. For instance, a doctor or health facility involved in your are may request certain of your protected health information that we hold n order to make decisions about your care.

Uses and Disclosures for Health Care Operations. We will make uses and disclosures of your protected health information as necessary for payment purposes. For instance, we may use information regarding your medical procedures and treatment to process and pay claims, to determine whether services are medically necessary or to otherwise pre-authorize or certify services as covered under your health benefits plan. We may also forward such information to another health plan, which may also have an obligation to process and pay any claims on your behalf.

Uses and Disclosures for Health Care Operations. We will use and disclose your protected health information as necessary, and as permitted by law, for our health care operations, which include credentializing health care providers, peer review, business management, accreditation and licensing, utilization review and management, quality improvement and assurance, enrollment, underwriting, reinsurance, compliance, auditing, rating, and other functions related to your health benefits plan. We may also disclose your protected health information to another health care facility, health care professional, or health plan for such things as quality assurance and case management, but only if that facility, professional, or plan also has or had a patient relationship with you. Family and Friends Involved In Your Care. With your approval, we may from time to time disclose your protected health information to designated family, friends, and others who are involved in your care or in payment for your care in order to facilitate that person’s involvement in caring for you or 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 protected health information with such individuals without your approval. If you have designated a person to receive information regarding payment of the premium on your long-term care or Medicare supplement policy, we will inform that person when your premium has not been paid. We may also disclose limited protected health information to a public or private entity that is authorized to assist in disaster relief efforts in order for that entity to locate a family member or other persons that may be involved in some aspect of caring for you.

Business Associates. Certain aspects and components of our services are performed through contracts with outside persons or organizations, such as auditing, accreditation, actuarial services, legal services, etc. At times it may be necessary for us to provide some of your protected health information to one or more of these outside persons or organization who assist us with our health care operations. In all cases, we require these business associates to appropriately safeguard the privacy of your information by contract.

Communications With You. We may communicate with you regarding your claims, premiums, or other things connected with your health plan or insurance. You have the right to request and we will accommodate reasonable requests. You must request such confidential communication in writing and send your request to your designated contact point as explained in the “Contact Information” section, below.

Other Health-Related Products or Services. We may, from time to time, use your protected health information to determine whether you might be interested in or benefit from treatment alternatives or other health-related programs, products or services which may be available to you as a member of the health plan. For example, we may use your protected health information to identify whether you have a particular illness, and contact your to advise you that a disease management program to help you manage your illness better is available to you as a health plan member. We will not use your information to communicate with you about products or services which are not health-related without your written permission.

Information Received Pre-enrollment. We may request and receive from you and your health care providers protected health information either prior to your enrollment in the health plan or the issuance of your policy. We will use this information to determine whether you are eligible to enroll either in the health plan or for a policy, and to determine your rates. We will protect the confidentiality of that information inthe same manner as all other protected health information we maintain and, if you either do not enroll in the health plan or if the policy is not issued, we will not use or disclose the information about you we obtained for any other purpose without your authorization.

Other Uses and Disclosures. We are permitted or required by law to make certain other uses and disclosures of your protected health information without your authorization. We may release your protected health information for any purpose required by law. This may include any of the following.

• We may release your protected health information for public health activities, such as required required reporting of disease, injury, and birth and death, and for required public health investigations;


• We may release your protected health information as required by law if we suspect child abuse or neglect; we may also release your protected health information as required by law if we believe your to be a victim of abuse, neglect, or domestic violence;


• We may release your protected health information to the Food and Drug Administration if necessary to report adverse events, product defects, or to participate in product recalls;


• We may release your protected health information to your plan sponsor; provided, however, your plan sponsor must certify that the information provided will be maintained in a confidential manner and not used for employment related decisions or for other employee benefit determinations or in any other manner not permitted by law.


• We may release your protected health information if required by law to a government oversight agency conducting audits, investigations, or civil or criminal proceedings;


• We may release your protected health information if required to do so by a court or administrative ordered subpoena or discovery request; in most cases you will have notice of such release;


• We may release your protected health information to law enforcement officials as required by law to report wounds and injuries and crimes;


• We may release your protected health information to coroners and/or funeral directors consistent with the law;


• We may release your protected health information if necessary to arrange an organ or tissue donation from you or a transplant for you;


• We may release your protected health information for certain research purposes when such research is approved by an institutional review board with established rules to ensure privacy;


• We may release your protected health information if you are a member of the military as required by armed forces services; we may also release your protected health information if necessary for national security or intelligence activities; and


• We may release your protected health information to workers’ compensation agencies if necessary for your workers’ compensation benefit determination.

OTHER PRIVACY LAWS AND REGULATIONS:

Certain other state and federal privacy laws and regulations may further restrict access to and uses and disclosures of your personal health information or provide you with additional rights to manage such information. If you have questions regarding these rights, please send a written request to your designated contact point as explained in the “Contact Information” section below.

RIGHTS THAT YOU HAVE

Access to Your Protected Health Information. You have the right to copy and/or inspect much of the protected health information that we retain on you behalf. All requests for access must be made in writing and signed by you or your personal representative. We may charge you a fee if you request a copy of the information. We will also charge for postage if you request a mailed copy and will charge for preparing a summary of the requested information if you request such summary. You may obtain an access request form form your designated contact point as explained in the “Contact Information” section, below.

Amendments to Your Protected Health Information. You have the right to request in writing that protected health information that we maintain about you be amended or corrected. We are not obligated to make all requested amendments but will give each request careful consideration. All amendment requests, in order to be considered by us, must be in writing, signed by you or your personal representative, and must state the reasons for the amendment/correction request. If an amendment or correction you request is made by us, we may also notify others who work with us and have copies of the uncorrected record if if we believe that such notification is necessary. You may obtain an amendment request form from you designated contact point as explained in the “Contact Information” section, below.

Accounting for Disclosures of Your Protected Health Information. You have the right to receive an accounting of certain disclosures made by us of your protected health information after April 14, 2003. Requests must be made in writing and signed by your designated contact point as explained in the “Contact Information” section, below. The first accounting in any 12-month period is free; you may be charged a fee for each subsequent accounting you request within the same 12-month period.

Restrictions on Use and Disclosure of Your Protected Health Information. you have the right to request restrictions on some of our uses and disclosures of your protected health information for treatment, payment, or health care operations by notifying us of your request for a restriction in writing. A restriction request form can be obtained from your designated contact point as explained in the “Contact Information” section, below. We are not required to agree to your restriction request but will attempt to accommodate reasonable requests when appropriate and we retain the right to terminate and agreed-to restriction if we believe such termination. You also have the right to terminate, in writing or orally, any agreed-to restriction to sending such termination notice to your designated contact point as explained in the “Contact Information” section, below.

Complaints. If you believe your privacy rights have been violated, you can file a complaint with your designated contact point as explained in the “Contact Information” section, below. You may also file a complaint with the Secretary of the U.S. Department of Health and Human Services, Office of Civil Rights, in writing within 180 days of a violation of your rights. There will be no retaliation for filing a complaint. Refer to the contact information below if you want to file a complaint.

CONTACT INFORMATION

If you have any questions about this statement, need copies of any forms or require further assistance with any of the rights explained above, please contact info@scarins.com As a member you retain the right to obtain a paper copy of this Notice of Privacy Practices, even if you have requested such copy by e-mail or other electronic means. This document is available for download in PDF format.

EFFECTIVE DATE

This Notice of Privacy Practices is effective April 14, 2003.