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.
When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.
You have the right to:
- Get a copy of your health and claims records
- Correct your health and claims records
- Request confidential communication
- Ask us to limit the information we share
- Get a list of those with whom we've shared your information
- Get a copy of this privacy notice
- Choose someone to act for you
- File a complaint if you believe your privacy rights have been violated
Get a copy of your health and claims records
- You can ask to see or receive a copy of your health records, claims records, and other health information we have about you. Ask us how to do this.
- We will provide a copy or a summary of your health and claims records, usually within 30 days of your request. We may charge a reasonable, cost-based fee.
Ask us to correct health and claims records
- You can ask us to correct your health and claims records if you think they are incorrect or incomplete. Ask us how to do this.
- We may say "no" to your request, but we'll tell you why in writing within 60 days.
Request confidential communications
- You can ask us to contact you in a specific way (for example, by home or office phone) or to send mail to a different address.
- We will consider all reasonable requests, and must say "yes" if you tell us you would be in danger if we do not.
Ask us to limit what we use or share
- You can ask us not to use or share certain health information for treatment, payment, or our operations.
- We are not required to agree to your request, and we may say "no" if it would affect your care.
Get a list of everyone with whom we've shared information
- You can ask for a list (accounting) of the times we've shared your health information for six (6) years prior to the date you ask, including who we shared it with and why.
- We will include all the disclosures except for those about treatment, payment, healthcare operations, and certain other disclosures (such as any you asked us to make). We'll provide one accounting per year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.
Get a copy of this privacy notice
- You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.
Choose someone to act for you
- If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.
- We will make sure your chosen person has authority and can act for you before we take any action.
File a complaint if you feel your rights are violated
- You can complain if you feel we have violated your rights by contacting us using the information below.
- You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter, calling (877) 696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/
U.S. Department of Health and Human Services Office for Civil Rights
200 Independence Avenue, S.W.,
Washington, D.C. 20201
- We will not retaliate against you for filing a complaint.
For certain health information, you have choices about what we share as we:
- Answer coverage questions from your family and friends
- Provide disaster relief
- Market our services and sell your information
If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.
In these cases, you have both the right and choice to tell us to:
- Share information with your family, close friends, or others involved in payment for your care
- Share information in a disaster relief situation
If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.
In these cases we never share your information unless you give us written permission:
- Marketing purposes
- Sale of your information
Our uses and disclosures
We may use and share your information as we:
- Help manage the health care treatment you receive
- Run our organization
- Pay for your health services
- Administer your health plan
- Help with public health and safety issues
- Do research
- Comply with the law
- Respond to organ and tissue donation requests and work with a medical examiner or funeral director
- Address workers' compensation, law enforcement, and other government requests
- Respond to lawsuits and legal actions
How do we typically use or share your health information?
We typically use or share your health information in the following ways:
To help manage the health care treatment you receive
- We can use your health information and share it with professionals who are treating you.
Example: A doctor sends us information about your diagnosis and treatment plan so we can arrange additional services.
To run our organization
- We can use and disclose your information to run our organization and to contact you when necessary.
- We are not allowed to use genetic information to decide whether we will give you coverage and to determine the price of that coverage. This does not apply to long-term care plans.
Example: We use your health information to develop better services for you.
To pay for your health services
- We can use and disclose your health information as we pay for your health services.
Example: We share information about you with your dental plan to coordinate payment for your dental work.
To administer your plan
- We may disclose your health information to your health plan sponsor for plan administration.
Example: Your company contracts with us to provide a health plan, and we provide your company with certain statistics to explain the premiums we charge.
How else can we use or share your health information?
We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.
Help with public health and safety issues
We can share health information about you for certain situations such as:
- Preventing disease
- Helping with product recalls
- Reporting adverse reactions to medications
- Reporting suspected abuse, neglect, or domestic violence
- Preventing or reducing a serious threat to anyone’s health or safety
- We can use or share your information for health research
Comply with the law
- We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law.
Respond to organ and tissue donation requests and work with a medical examiner or funeral director
- We can share health information about you with organ procurement organizations.
- We can share health information with a coroner, medical examiner, or funeral director when an individual dies.
Address workers' compensation, law enforcement, and other government requests
We can use or share health information about you:
- For workers' compensation claims
- For law enforcement purposes or with a law enforcement official
- With health oversight agencies for activities authorized by law
- For special government functions such as military, national security, and presidential protective services
Respond to lawsuits and legal actions
- We can share health information about you in response to a court order, administrative order, or a subpoena.
Use and disclosure of the specific types of medical information
There are stricter requirements for use and disclosure of some types of information – for example, patient information related to mental health, drug and alcohol abuse, or and HIV test results. However, there are still circumstances in which these types of information may be used or disclosed without your authorization.
Abuse or neglect:
By law, we may disclose your medical information to the appropriate authority to report suspected elderly abuse or neglect to identify suspected victims of abuse, neglect, or domestic violence.
Under the federal law that requires us to give you this notice, inmates do not have the same rights to control their medical information as other individuals. If you are an inmate of a correctional institution or in custody of a law enforcement official, we may disclose your medical information to the correctional institution or the law enforcement for certain purposes – for example, to protect your health or safety or someone else's.
All other uses and disclosures of your medical information require your prior written authorization:
Except for those uses and disclosures described above, we will not use or disclose your medical information without your written authorization. If you have already given authorization in a case where it was required, you may revoke that authorization at any time by notifying us in writing. Please note that the revocation will not apply to any authorized use or disclosure of your medical information that took place before we received your revocation.
- We are required by law to maintain the privacy and security of your protected health information.
- We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
- We must follow the duties and privacy practices described in this notice and give you a copy of it.
- We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.
For more information, see www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html
Changes to the terms of this notice
We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, on our web site, and we will mail a copy to you.
If you have questions about this notice, or want to lodge a complaint about our privacy practices, please let us know by calling our Member Services or or call Blue Shield of California Promise Health Plan's Hotline.
Blue Shield Promise Cal MediConnect Member Services phone: (800) 605-2556 (TTY: (800) 735-2929, 8 a.m. - 6 p.m.
Blue Shield of California Promise Health Plan Hotline phone: (888) 266-8080
You may also write to our Privacy Office, at
Blue Shield of California Promise Health Plan
Attention: Privacy Office
PO Box 272540
Chico, CA 95927-2540
You may also file a complaint with and notify Department of Health Care Services (DHCS):
Department of Health Care Services (DHCS)
C/O Office of HIPAA Compliance DHCS
P.O. Box 997413, MS 4722,
Sacramento, CA 95899-7413
Email Privacy Officer: firstname.lastname@example.org
Phone: (916) 445-4646
Fax: (916) 440-7680
We will not take retaliatory action against you if you file a complaint about our privacy practices.
Effective Date: 09/23/2013
Use this form to authorize Blue Shield of California Promise Health Plan to use or to disclose your health information to another person or organization:
Authorization for the Use or Disclosure of Health Information, English (PDF, 296 KB)
Authorization for the Use or Disclosure of Health Information, Chinese (PDF, 403 KB)
Authorization for the Use or Disclosure of Health Information, Hindi (PDF, 450 KB)
Authorization for the Use or Disclosure of Health Information, Korean (PDF, 546 KB)
Authorization for the Use or Disclosure of Health Information, Spanish (PDF, 298 KB)
Authorization for the Use or Disclosure of Health Information, Vietnamese (PDF, 498 KB)