Health Insurance Portability and Accountability Act

The Health Insurance Portability and Accountability Act(HIPAA) was enacted by the U.S. Congress in 1996. According to the Centers for Medicare and Medicaid Services (CMS) website, Title I of HIPAA protects health insurance coverage for workers and their families when they change or lose their jobs. Title II of HIPAA, known as the Administrative Simplification (AS) provisions, requires the establishment of national standards for electronic health care transactions and national identifiers for providers, health insurance plans, and employers.

The Administration Simplification provisions also address the security and privacy of health data. The standards are meant to improve the efficiency and effectiveness of the nation's health care system by encouraging the widespread use of electronic data interchange in the US health care system.

Fortier Insurance Services HIPAA

Disclosure

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

This notice is solely for your information. You do not need to take any action. You have received this notice because Roger Fortier is a business associate of your health insurer or your health plan provider. This notice refers to Roger Fortier and its affiliates, agents, subcontractors, employees and business associates by using the terms "us", "we" and "our". We understand the importance of keeping your medical and personal information ("Personal Information") confidential. This notice of our privacy practices describes generally how we may use and disclose this Personal Information to administer your benefits and other purposes that are permitted or required by law, and how we protect the security and confidentiality of your Personal Information. This notice also explains your rights regarding the information.

Personal information includes medical, financial, demographic and other information about you or your dependents that we obtain in arranging for your benefit coverage or administering your benefits. This notice applies to all of the records that we receive to administer your benefits. Your provider(s) may have different policies or notices regarding such provider's use and disclosure of your personal information created or used within the provider's office or dispensary.

We are required by the federal privacy regulations to keep Personal Information about you private; give you this notice of our legal duties and privacy practices with respect to your Personal Information; and follow the terms of the notice that are currently in effect.

HOW WE MAY USE AND DISCLOSE PERSONAL INFORMATION.

In administering your benefits, we obtain personal information about you and your dependents. In performing our duties, we may use and disclose this information in various ways. We have provided you with examples in certain categories, however, not every use or disclosure in a category will be listed. Such uses and disclosures include:

Payment: To process payment of your benefits services, we may use and disclose personal information about you in several ways, such as, to determine eligibility, collect premiums, investigate and respond to complaints or appeals, conduct utilization reviews, pay your participating providers or reimburse you for benefits services or products that you received, including sending an explanation of benefits to the subscriber. For example, we may upon your provider's request disclose that you are enrolled in the benefit plan(s) and the benefits available so you may receive services and/or products.

Health Care Operations: We may use and disclose personal information about you for certain operational, administrative and quality assurance activities related to your benefit plans. This includes disclosing information to the plan providers which will assist them in operational activities, such as underwriting and rating of the plan, audits of your claims, quality of care reviews, investigation of fraud, performance measurements, and care coordination. We may also combine personal information about many participants to decide what additional services may be covered, what services or products are not needed and the appropriate premium rate to charge. We may remove information that identifies you from the personal information so we may use it to study health care delivery without disclosing the identity of specific patients.

Treatment : We may disclose information to health care providers who treat you. For example, doctors may request a copy of information for their own records.

Services and/or Products Alternatives: W e may use and disclose personal information to tell you about alternative treatment, services, products or options, e.g., new benefits available.

Dependents Protected Health Information: We may release personal information about your dependents to you. We may provide you with an explanation of benefits for you or any of your dependents.

Additional Uses or Disclosures : We may disclose personal information about you concerning: Public Health or Safety to address situations as permitted by law, including to report problems with products or product recall notices, threat to public health and safety, including disaster relief effort or national security. Military as required by military command authorities if you are serving in the military. Organ and Tissue Donation to assist in organ or tissue donation and transplantation. Lawsuits and Disputes to respond to a court or administrative order or other lawful process. Law Enforcement to respond to a federal state or local law enforcement official or to a correctional institution if you are an inmate. Coroners, Medical Examiners Regulatory or administrative oversight to state insurance departments, Office of Civil Rights, Department of Health and Human Services and other agencies that regulate us. Plan Administration to the health plans and programs in which you are a participant for purposes of coordination of benefits. Contractors to persons who provide services to us who will be required to protect your personal information.

Disclosure As You Request: We may disclose Personal Information to people involved with your receipt of health care. In addition, uses and disclosures of personal information not covered by this notice or the laws that apply to us will be made only with your written permission, identified as an authorization. If you provide us with an authorization, you may revoke that permission at any time by contacting us by telephone at (760) 868-6470 or e-mail at or by mail to:

Fortier Insurance Services

Attn: Privacy Officer

P.O. Box 291459

Phelan,CA 92329

If you revoke your permission, we will no longer use or disclose personal information about you for the reasons stated in your authorization. You understand that we are unable to take back any disclosures we have already made with your permission.

YOUR RIGHTS REGARDING PERSONAL INFORMATION.

You have the following rights regarding your Personal Information:

Right to Inspect and Copy: You have the right to inspect and copy Personal Information that we maintain. If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other supplies associated with your request, as allowed by law.

Right to Amend: If you feel that personal information we have about you is incorrect or incomplete, you may ask us to amend the information that is contained in a "designated record set", e.g., information used to make payment and other decisions. You have the right to request an amendment for as long as we keep the information. We may deny your request for an amendment if it is not in writing or does not include a reason to support the request or the current information is accurate and complete or if we did not create the information.

Right to an Accounting of Disclosures: You have the right to request a list of our disclosures for purposes other than treatment, payment or health care operations. Your request must state a time period and may not include dates before April 14, 2003. If you request more than one list in a year, we may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.

Right to Request Restrictions: You have the right to request to restrict the way we use or disclose personal information regarding treatment, payment or health care operations. You also have the right to request to restrict the Personal Information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend. We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you with emergency treatment. In your request, you must tell us (1) what information you want to restrict; (2) whether you want to restrict our use, disclosure or both; and (3) to whom you want the restrictions to apply, for example, disclosures to your spouse.

Right to Request Confidential Communications: You have the right to request that we communicate personal information to you in a certain way or at a certain location. Your request must specify how or where you wish to be contacted. We will comply with reasonable requests.

Right to a Paper Copy of This Notice: You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice upon request.

You may request any of the above described by calling our  Benefits Privacy Office at (760) 868-6470 or submitting the request by e-mail to or by submitting your request by mail to:

Fortier Insurance Services

Attn: Privacy Officer

P.O. Box 291459

Phelan,CA 92329

COMPLAINTS

If you believe your privacy rights have been violated, you may file a complaint with us. To file a complaint call (760) 868-6470, e-mail the complaint to or mail the complaint to:

Fortier Insurance Services

Attn: Privacy Officer

P.O. Box 291459

Phelan,CA 92329

Include your name, address and telephone number and we will respond.

You may also contact the Secretary of the Department of Health and Human Services. You will not be penalized for filing a complaint.

CHANGES TO THIS NOTICE

We may change the terms of this notice and our privacy policies. If we make such changes, the new terms and policies will apply to all Personal Information (past and future) that we maintain. If we make material changes, we will send a new notice to the subscribers. If you have any questions regarding this notice, please call the our Privacy Office (760) 868-6470 or e-mail at and leave a message, or you may contact:

Fortier Insurance Services

Attn: Privacy Officer

P.O. Box 291459

Phelan,CA 92329

Please include your name, address and telephone number and we will respond.