As a participant in my Employers' Group Health Plan (the "Plan"), I hereby authorize the issuance of a password and the use or disclosure of, including access to, my Protected Health Information (as defined in the Privacy Standards) as described in this Authorization.
It is my desire that a password be issued so that I may access information regarding my claims under the Plan, as well as those of my dependents, if any, (the "Dependents"). Further, I may wish to disclose this password to the Dependents. I recognize that by issuance and use of this password, I am authorizing the third party administrator of the Plan, Tucker Administrators, Inc. ("TPA"), to disclose to the Dependents and I my Protected Health Information.
*The Protected Health Information that may be accessed and disclosed through use of the password includes, with respect to me and the Dependents who are covered under the Plan, the following:
Information regarding enrollment in the Plan.
Information regarding claims filed, including date of service, provider of service, amount charged and general description of services rendered.
Information regarding payment and denial of claims, including the reason for denial of any claims.
I understand that if I make this password available to the Dependents, it will allow them to access the information described in Item 3 above and I hereby authorize such access.
This Authorization shall expire within ten business days following my termination as a participant in the Plan.
I understand that I have the right to revoke this Authorization by delivering a written notice of my desire to revoke this Authorization to TPA at their offices at 3800 Arco Corporate Drive, Charlotte, NC 28273, Suite 450, Attn: Carol Ann Pencek/Vice President. The revocation will be effective ten business days following TPA's receipt of my written notice. I understand that I cannot revoke this Authorization to the extent that the Plan or TPA, on behalf of the Plan, has taken action in reliance on this Authorization (for example, any disclosure made prior to the revocation under this Authorization will not be affected by the revocation).
Collection of Information
You may be asked to voluntarily provide your name, birth date, social security number, email address, and zip code ("Personal Information") to have access to some features of the Site. By using the Site and providing us with your Personal Information, you consent to our use of such information as described in this Policy. You may always refuse to provide your Personal Information, and this may lead to our inability to provide you with certain products or services.
*I understand that the information described above, once disclosed to the Dependents, may be re-disclosed by those individuals and no longer protected by the Privacy Standards.
I understand that this Authorization is not required for the Plan to use or disclose any Protected Health Information for purposes of treatment, payment or health care operations, or if the use or disclosure is otherwise permitted by the Privacy Standards, and that any revocation of this Authorization will have no effect on such uses or disclosures.
I understand that the Plan may not condition my enrollment or eligibility for, or payment of, benefits on my agreeing to this Authorization. I also understand that I am entitled to receive a copy of this Authorization.
I agree to protect the confidentiality of the password to prevent unauthorized persons from accessing or using my Protected Health Information or the Protected Health Information of the Dependents. If I have reason to believe the password has become known to any unauthorized person, I immediately will notify TPA, so that the password may be changed.
I release the Plan, the Plan Administrator and TPA from any and all liability that may arise from improper access, use or disclosure of my Protected Health Information by the Dependents or unauthorized persons using the password.
In connection with providing services to you, Tucker Administrators, Inc. may also obtain nonpublic health information about you including, but not limited to, information about your eligibility for health care benefits, your claims history, your medical history or other information relating to the maintenance or administration of your health care benefits ("Health Information").
Except as expressly set forth in this Policy, we will not disclose any Health Information about current or former customers to anyone, except as permitted by law. We may provide Health Information that we collect to affiliated or nonaffiliated parties involved in underwriting, processing, servicing and marketing our insurance related products and services. Except as stated in this Policy and as permitted by law, we will not disclose your Health Information to nonaffiliated third parties, unless we first obtain your authorization or offer you an opportunity to opt out of such disclosure.
Use of Information
We use your Personal Information and Health Information for the following purposes: to administer your account; to administer and improve the Site and related services; to notify you of our products, services, promotional events or special offers that maybe of interest to you; to provide Internet security; and to meet legal requirements. We may work with our business partners who may perform certain functions on our behalf, such as underwriting, processing, servicing and marketing our insurance related products and services, sending email messages, managing data or providing customer service. These business partners have access to your Personal Information only to the extent necessary to perform these specific functions and may not use it for any other purpose. If Tucker Administrators, Inc. is involved in the sale of a substantial portion of its business assets, Personal or Health Information may be among the transferred assets.
When you send an email to us, you are communicating with us electronically. You thereby consent to receive communications from us electronically. We will communicate with you by email or by posting notices on the Site. All agreements, notices, disclosures and other communications that we provide to you electronically satisfy any legal requirement that such communications be in writing.
Privacy of Children
We encourage parents and guardians to be aware of and participate in their children's online activities. We strictly adhere to the Children's Online Privacy Protection Act and will not knowingly collect, use or disclose Personal Information from any child under the age of 13 in any manner that violates this law.
The Site may contain links to other sites on the Internet that are owned and operated by third parties. Tucker Administrators, Inc. is not responsible for the collection or use of your Personal or Health Information at any third party sites. Therefore, Tucker Administrators, Inc. disclaims any liability for any third party's use of your Personal or Health Information obtained through using a third party web site.
We have policies and procedures in place to protect the privacy and confidentiality of your Personal and Health Information that we collect and maintain. All Personal and Health Information is stored on our secured servers, behind a firewall at a data center with access to data strictly controlled. Additionally, we restrict access to Health Information to those employees who need to know that information to provide services to you. Any unauthorized use of the Site may result in criminal and/or civil prosecution.
Contacting Us or Modifying Your Personal Information
If you have any questions or comments about this Policy, please contact Carol Ann Pencek/Vice President at 704-227-3902. Please provide a concise communication with complete information, including your contact information. If you wish to update your Personal Information provided to us, please contact your employer.