Public Employees’ Benefits Program is committed to maintaining privacy and confidentiality of information to which it has been entrusted. Please read the following notice for further clarification of these Federal regulations.

The Effective Date of This Notice is April 14, 2003.

Privacy Notice to All Plan Participants and Their Dependents:

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

 Public Employees’ Benefits Program (PEBP) is required by law to maintain the privacy of “protected health information.” “Protected health information” includes any identifiable information that we obtain from you or others that relates to your physical or mental health, the health care you have received, or payment for your health care.

As required by law, this notice provides you with information about your rights and PEBP’s legal duties and privacy practices with respect to the privacy of protected health information. This notice also discusses the uses and disclosures PEBP will make of your protected health information.

PEBP reserves the right to change the terms of this notice from time to time and to make the revised notice effective for all protected health information we maintain. You can always request a copy of our most current privacy notice from our office or you can access it on our web site.

PERMITTED USES AND DISCLOSURES

PEBP can use or disclose your protected health information for purposes of treatment, payment and health care operations. Treatment means the provision, coordination or management of your health care, including referrals for health care from one health care provider to another. For example, a provider under the PEBP plan may need to know health care information in plan files that might assist in treatment. Payment means activities to obtain and provide reimbursement for health care provided to you, including determinations of eligibility and coverage and other utilization review activities. For example, the information on or accompanying health care bills sent to the plan includes data that identifies you, as well as your diagnosis, procedures, and supplies used. This information is used to determine benefits and payments. As another example, prior to providing health care services, PEBP may need information from a provider about your medical condition to determine whether the proposed course of treatment will be covered.

Health care operations means the support functions related to treatment and payment, such as quality assurance activities, case management, receiving and responding to patient complaints, physician reviews, compliance programs, audits, business planning, development, management and administrative activities. For example, PEBP may use your medical information to evaluate the performance of providers used in the plan. PEBP may also combine medical information about many patients to decide how to better provide needed benefits under the plan.

OTHER USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION

 PEBP may contact you to provide information about treatment alternatives or other health related benefits and services that may be of interest to you.

 PEBP may disclose your protected health information to your family or friends or any other individual identified by you when they are involved in your care or the payment for your care. PEBP will only disclose the protected health information directly relevant to their involvement in your care or payment. PEBP may also use or disclose your protected health information to notify, or assist in the notification of, a family member, a personal representative, or another person responsible for your care, of your location, general condition, or death. If you are available, PEBP will give you an opportunity to object to these disclosures, and the plan will not make these disclosures if you object. If you are not available, PEBP will determine whether a disclosure to your family or friends is in your best interest, and the plan will disclose only the protected health information that is directly relevant to their involvement in your care. When permitted by law, PEBP may coordinate uses and disclosures of protected health information with public or private entities authorized by law or by charter to assist in disaster relief efforts.

Except for the situations set forth in this notice, PEBP will not use or disclose your protected health information for any other purpose unless you provide written authorization.

You have the right to revoke that authorization at any time, provided that the revocation is in writing, except to the extent that PEBP already has taken action in reliance on your authorization.

EXCEPTIONAL SITUATIONS

 PEBP may use or disclose your protected health information in the following situations without your authorization:

Coroners, Medical Examiners and Funeral Directors. PEBP may release medical information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. PEBP may also release medical information about patients to funeral directors as necessary to carry out their duties.

Health Oversight Activities. PEBP may disclose medical information to federal or state agencies that oversee our activities. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws. PEBP may disclose protected health information to persons under the Food and Drug Administration’s jurisdiction to track products or to conduct post-marketing surveillance.

Inmates. If you become an inmate of a correctional institution or fall under the custody of a law enforcement official, the plan may release medical information about you to the correctional institution or law enforcement official. This release would be necessary for the institution to provide you with health care; to protect your health and safety or the health and safety of others; or for the safety and security of the correctional institution.

Law Enforcement. PEBP may release medical information in these situations: if asked to do so by a law enforcement official in response to a court order, subpoena, warrant, summons or similar process; to identify or locate a suspect, fugitive, material witness, or missing person; about the victim of a crime if, under certain limited circumstances, PEBP is unable to obtain the person’s agreement; about a death that may be the result of criminal conduct; about criminal conduct on PEBP premises; and in emergency circumstances to report a crime; the location of the crime or victims or the identity, description or location of the person who committed the crime.

Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, PEBP may disclose medical information about you in response to a court or administrative order. PEBP may also disclose medical information about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.

Military and Veterans. If you are a member of the armed forces, PEBP may release medical information about you as required by military command authorities. PEBP may also release medical information about foreign military personnel to the appropriate foreign military authority.

National Security and Intelligence Activities. PEBP may release medical information about you to authorized federal officials for intelligence, counterintelligence, or other national security activities authorized by law.

Organ and Tissue Donation. If you are an organ donor, PEBP may release medical information to organizations that handle organ procurement or organ, eye or tissue transplantation, or to an organ donation bank, as necessary to facilitate organ or tissue donation and transplantation.

Protective Services for the President and Others. PEBP may disclose medical information about you to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state or conduct special investigations. Public Health Risks. PEBP may disclose medical information about you for public health activities. These activities generally include the following: to prevent or control disease, injury or disability; to report births and deaths; to report child abuse or neglect; to report reactions to medications or problems with products; to notify people of product, recalls, repairs or replacements; to notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition; to notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect or domestic violence. PEBP will only make this disclosure if you agree or when required or authorized by law.

Serious Threats. As permitted by applicable law and standards of ethical conduct, PEBP may use and disclose protected health information if, in good faith, it believes that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public.

Workers’ Compensation. PEBP may release medical information about you for programs that provide benefits for work-related injuries or illness.

YOUR RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOU

You have the following rights regarding medical information we maintain about you:

 Right to Inspect and Copy. You have the right to inspect and copy medical information that may be used to make decisions about your care. Usually, this includes medical and billing records, but does not include psychotherapy notes.

To inspect and copy medical information that may be used to make decisions about you, you must submit your request in writing to the PEBP Privacy Officer at the address below. 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.

We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to medical information, you may request that the denial be reviewed.

Right to Amend. If you feel the medical information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept.

To request an amendment, your request must be made in writing and submitted to our Privacy Officer. In addition, you must provide a reason that supports your request.

PEBP may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, PEBP may deny your request if the amendment involves information that: (1) Was not created by PEBP, unless the person or entity that created the information is no longer available to make the amendment; (2) Is not part of the medical information kept by PEBP; (3) Is not part of the information which you would be permitted to inspect or copy; or (4) Is accurate and complete.

Right to an accounting of disclosures. You have the right to request an “accounting of disclosures.” This is a list of any disclosures outside of normal disclosures such as treatment, payment and operations. It would also exclude disclosures made pursuant to your authorization, or those made for national security and intelligence purposes, and those made to correctional institutions, government agencies and law enforcement in compliance with Federal, State, or local law.

To request this list or accounting of disclosures, you must submit your request in writing to the PEBP Privacy Officer. Your request must state a time period that may not be longer than six years and may not include dates before April 14, 2003. Your request should indicate in what form you want the list (for example, on paper or electronically). The first list you request in a 12-month period will be free. For additional lists, PEBP may charge you for the costs of providing the list.

(Note from PEBP: At the time of this notice, PEBP does not permit any disclosures of information, internally or between business associates, that are not directly necessary for the administration of your contracted benefits. For example, any business associate that has a contract with PEBP to offer benefits to State Employees would have a right to contact information if it were necessary to ensure that benefits were understood and being used appropriately. Those are necessary disclosures. Otherwise, PEBP does not sell mailing lists to other vendors, sales companies, or telemarketers. That would constitute an outside disclosure of your information. Currently, any request for this outside disclosure accounting would find nothing to be disclosed.)

Right to Request Restrictions. You have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment, payment or health care operations. You also have the right to request a limit on the medical 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. For example, if you do not want the PEBP Member Services to speak to your spouse about your information, you may request that restriction.

PEBP is not required to agree to your request, but will comply with the request unless the information is needed to provide emergency treatment.

To request restrictions, you must make your request in writing to the PEBP Privacy Officer. In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit PEBP’s use or disclosure, or both; (3) to whom you want the limits to apply, and (4) for how long.

(Note from PEBP: You can call and request a HIPAA authorization form that has all these items on it.)

Right to Request Confidential Communications. You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail.

To request confidential communications, you must make your request in writing to the PEBP Privacy Officer. PEBP will not ask you the reason for your request and will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted. If complying with your request entails additional expense over our usual means of communication, we may ask that you reimburse us for those expenses.

Right to a Paper Copy of This Notice. You have the right to a paper copy of this notice at any time, even if you have agreed to receive this notice electronically. To obtain a paper copy of this notice you can check with any usual source of PEBP forms and documents, including the PEBP website, or request one in writing from the PEBP Privacy Officer.

COMPLAINTS

If you believe your privacy rights have been violated, you may file a complaint with PEBP, or with the Secretary of the Department of Health and Human Services. To file a complaint with PEBP, submit the written complaint to:

PEBP Privacy Officer

901 South Stewart Street, Suite 1001

Carson City NV 89701

 Phone (775) 684-7000 Or (800) 326-5496 Fax (775) 684-7028

You also may file a complaint with the:

Department of Health and Human Services

Office of Civil Rights Department of Health and Human Services

 Room 322 San Francisco CA 94102

(415) 437-8310 or TDD line (415) 437-8311

You will not be penalized for filing a complaint.