Notice of Privacy Practices

Effective April 14, 2003

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.

To fulfill our responsibilities to you, the Plan may use and disclose your protected health information for treatment, payment, and healthcare operations, or when we are otherwise required or permitted to do so by law. Below is further detail explaining these situations.

Treatment. We may use and disclose protected health information with your healthcare providers (physicians, pharmacies, hospitals and others) to assist in the diagnosis and treatment of your injury or illness. For example, we may disclose your protected health information to suggest treatment alternatives.

Payment. We may use and disclose protected health information to pay for your covered health expenses. For example, we may use protected health information to process claims. We may also ask a healthcare provider for details about your treatment so that we may pay the claim for your care.

Healthcare Operations. We may use and disclose protected health information for our healthcare operations. For example, we may use or disclose protected health information to perform quality assessment activities or provide you with case management services.

Business Associates. At times we may need to use the services of other companies in lieu of our own staff, such as outsourcing data entry services. Also, as part of our routine business, we may require outside entities such as auditors perform operations that require access to our healthcare information. In order for us to share confidential information with these organizations, we must enter into agreements that require them to comply with the privacy regulations of the Plan.

Plan Sponsor. If you participate in a self-funded group health plan through your employer (plan sponsor), we may share limited health information with your employer as necessary to perform administrative functions. Plan sponsors that receive this information are required by law to have safeguards in place to protect against inappropriate use or disclosure of your information.

You or Your Personal Representative. We must disclose your health information to you as described in the section below entitled “Your Rights Regarding Your Protected Health Information”. If you have a legally assigned personal representative or are an unemancipated minor, we will release the information to your personal representative or parent(s) as required by law.

Family/Friends. We may disclose your health information to a family member or friend to the extent necessary to help with your healthcare or with payment for your healthcare if you agree that we may do so. If you wish to designate a person(s) to whom we may discuss your healthcare, you may submit a request to the address listed below. If you are physically or mentally unable to participate in decisions regarding your healthcare, we may need to communicate with a family member to the extent necessary to insure that you receive appropriate healthcare treatment.

Permitted or Required by Law. We must disclose protected health information about you when required to do so by law. Information about you may be used or disclosed to regulatory agencies, such as Medicare and Medicaid, for administrative or judicial hearings, public health authorities, or law enforcement officials, and to comply with a court order or subpoena.

Member Authorization

Other uses or disclosures of your protected health information will be made only with your written authorization, unless otherwise permitted or required by law. You may revoke an authorization at any time in writing, except to the extent that we have already taken action on the information disclosed or if we are permitted by law to use the information to contest a claim or coverage under the Plan.

Your Rights Regarding Your Protected Health Information

You have the following rights regarding protected health information that the Plan maintains about you. If you wish to exercise any of these rights, you may submit your request in writing.

• Right to Access Your Protected Health Information. You have the right to inspect and/or obtain a copy of individual protected health information that we maintain about you. We may charge a fee for the costs of producing, copying and mailing your requested information, but we will tell you the cost in advance.

• Right to Amend Your Protected Health Information. You have the right to request an amendment of individual protected health information that we maintain about you. All requests must be in writing and must include the reason for the change.

• Right to an Accounting of Disclosures by the Plan. You have the right to request an accounting of nonroutine disclosures of individual protected health information made by the Plan on or after the compliance date of April 14, 2003. All requests must be in writing and must state the period of time for which you want the accounting. We may charge for providing the accounting, but we will tell you the cost in advance.

• Right to Request Restrictions on the Use and Disclosure of Your Protected Health Information. You have the right to request that the Plan restricts the use and disclosure of your protected health information for treatment, payment, or healthcare operations. The Plan is not required to agree to the requested restriction; however, if the Plan does agree to the restriction, it must comply with your request unless the information is needed for an emergency.

• Right to Receive Confidential Communications. You have the right to request to receive communication of protected health information from the Plan through an alternative procedure (other than the standard means of communicating protected health information). All requests must be in writing and are subject to technical reasonability for the Plan.

• Right to a Paper Copy of This Notice. You have the right at any time to receive a paper copy of this Notice, even if you had previously agreed to receive an electronic copy.

Changes

Complaints

If you believe your privacy rights have been violated, you have the right to file a complaint with the Plan and/or with the federal government. Complaints to the Plan may be directed to the appropriate Member Services department listed at the end of this Notice or by calling the Member Services number listed on the back of your ID card. You may also file a complaint anonymously by calling the Plan’s Fraud and Abuse Hotline at 1-877-349-5997. Complaints to the government may be sent to: Secretary of the Department of Health and Human Services, 200 Independence Avenue, S.W., Washington, D.C. 20201. You will not be penalized for filing a complaint.

Contact the Plan