HEYDE COMPANIES

Notice of Privacy Practices

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

PURPOSE OF THIS NOTICE:

We keep our employees’ health insurance related information private as required by law.  This notice explains your rights, our legal duties and our privacy practices.

YOUR HEALTH RELATED INFORMATION:

As part of the enrollment and/or claim process we may on occasion receive personal health information.  This information includes information that you give us on applications or other forms, such as your name, address, age, and dependants, etc…

We will use physical and procedural methods to protect your private information.  We share it only with our employees and insurance carrier, with which the issue is involved, who need it to provide service on your policy, to do insurance business, or for other legally allowed or required purposes.

FOR PAYMENT:

We may use and disclose information about you to manage your accounts or benefits that you receive from the current or previous health plans.  For example, in an attempt to assist with a claim question we may disclose benefit or deductible levels to your providers.  However, in most cases these questions would be referred to the current health insurance provider.

FOR HEALTH CARE OPERATIONS:

We use and disclose information about you for our operations.  For example, we may use information about you to: review the quality of health insurance plans, for bidding out to prospective health insurance carriers to evaluate plan options.

AS ALLOWED OR REQUIRED BY LAW:

Heyde Companies will use or disclose your medical information if a federal, state or local law requires us to do so.

WRITTEN AUTHORIZATION:

We will get your written permission before we use or share your protected health information for any other purpose, unless otherwise stated in this notice.  You may withdraw your permission at any time, in writing.  We will then stop using your information for that purpose.  However, if we have already used or shared your information based on your authorization, we cannot undo any actions we took before you withdrew your permission.

YOUR RIGHTS CONCERING YOUR MEDICAL INFORMATION: 

You have the following rights associated with your medical information:

Ø      Ask us not to use your health information for payment or health care operations activities.  We are not required to agree to these requests.

Ø      See or get a copy of information that we have about you, or ask that we correct your personal information that you believe is missing or incorrect. 

Ø      Ask us to communicate with you about health matters using reasonable alternative means or at a different address, if communications to your home address could endanger you.

For example by use of e-mail or a post office box.   You must make your request in writing to Heyde Companies’ contact person. Your request must include the method or location desired as well as effective date.

Ø      Receive a list of disclosures of your health information that we make on or after April 14, 2004, except when:

-         You have authorized the disclosure;

-         The disclosure is made for payment or health care operations; or

-         The law otherwise restricts the accounting

RIGHT TO MAKE A COMPLAINT

If you believe your privacy rights have been violated, you may file a written complaint with Heyde Companies’ contact person or with the Office for Civil Rights in the US Department of Health and Human Services.  We will not take action against you for filing a complaint.

RIGHT TO A PAPER COPY OF THIS NOTICE:

You have the right to request a paper 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.

HEYDE COMPANIES RIGHT TO REVISE THIS NOTICE:

Heyde Companies reserves the right to change the terms of this notice at any time.  We are required by law to comply with whatever privacy notice is currently in effect.  A revised notice will apply to information we already have about you as well as any information we may receive in the future.  We will communicate any changes to our notice through payroll stuffers, mail and/or our web-site. 

CONTACT INFORMATION:

To obtain a copy of the most current notice, to exercise any of your rights described in this notice, or to receive further information about the privacy of your medical information or to file a complaint, you may contact Heyde Companies’ contact person at:

                                                Jenny Risinger, Privacy Officer

                                                Heyde Companies

                                                345 Frenette Drive

                                                Chippewa Falls, WI  54729

                                                715-726-9176

                                                800-435-2964

            Effective Date April 14, 2004

        Revised August 10, 2004.

HEYDE COMPANIES
PRIVACY NOTICE ACKNOWLEDGEMENT

I hereby acknowledge that I have been advised of the privacy practices of Heyde Companies.

_________________________   _______________________                

Employee Name                                       Signature  

_________________________   _______________________

Facility                                              Date

q       Check if employee is a minor.

___________________      __________________                  _________

Parent/Guardian Name                   Signature                                Date