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Other Uses and Disclosures Allowed Without Authorization The Plan may use and disclose PHI, without your authorization, in the following ways;

To you, as the covered individual; To a personal representative designated by you to receive PHI or a personal representative designated by law, such as the guardian ad litem for a minor or a person with power of attorney for health care; To the Secretary of Health and Human Services (HHS) or a duly designated employee of HHS as part of an investigation to determine the Plan’s compliance with HIPAA; In response to a court order, subpoena, discovery request, or other lawful judicial or administrative proceeding or process; As required for federal, state, and local law enforcement purposes; As required to comply with Workers’ Compensation or other similar programs established by law; To a health oversight agency for activities authorized by law such as audits,

investigations, and include government

inspections. agencies that

Oversight agencies seeking this information oversee benefit programs, other governmental

regulatory programs, and civil rights laws; As required to address certain matters of







by law. Examples include and To the State and School Plan Sponsor, provided Document, to carry out discussed above.

threats to the public health or national security matters;

Employees Health Insurance Management Board, the the appropriate language is included in the Plan the payment and health care operations functions

USES AND DISCLOSURES REQUIRING YOUR WRITTEN AUTHORIZATION Other uses and disclosures of your PHI will only be made upon receiving your written authorization. If you have provided an authorization to the Plan, you may revoke your authorization at any time by providing written notice to the Plan. The Plan will honor a request to revoke as of the day it is received and to the extent that the Plan has not already used or disclosed your PHI.

YOUR RIGHTS IN RELATION TO PROTECTED HEALTH INFORMATION The federal privacy regulations give you the right to make certain requests regarding your PHI.

Right to Request Restrictions You have the right to request that the Plan restrict its uses and disclosures of PHI in relation to treatment, payment, and health care operations. Any such request must be made in writing and must state the specific restriction requested and to whom that restriction would apply. The Plan is not required to agree to a restriction that you request.


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