Authorization for Use of Websites, Mobile Applications, and Passwords
This information is provided in accordance with the Standards for Privacy of Individually Identifiable Health Information (the "Privacy Standards") issued under the Health Insurance Portability and Accountability Act of 1996, as amended ("HIPAA & HITECH Act").
I, understand, acknowledge, and agree to the following:
- As a participant in my Employers' Group Health Plan (the "Plan"), and 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). Further, I may wish to disclose this password to my dependents (the "Dependents").
- The Protected Health Information that may be accessed and disclosed through use of the password includes, with respect to myself 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 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 my Dependents, it will allow them to access the information described in Item 3 above.
- I understand that I have the right to revoke this Authorization by delivering a written notice of my desire to revoke this Authorization to Professional Benefit Administrators, Inc. (PBA) at their offices located at 900 Jorie Blvd., Oak Brook, IL 60522, Attn: Customer Service Manager. The revocation will be effective ten business days following PBA's receipt of my written notice. I understand that I cannot revoke this Authorization to the extent that the Plan or PBA, on behalf of the Plan, have 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).
- I understand that the information described in Item 3 above, once disclosed to the Dependents, it 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 accepting this Authorization.
- I agree to protect the confidentiality of my 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 have the ability to change the password at any time.
- I release the Plan, the Plan Administrator and PBA 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.
We understand that our customers, Website, and Mobile Application users/visitors are concerned about the privacy of information. We have established policies and procedures concerning the collection, use and security of all your information that will help protect your privacy. Our Information Privacy Policies are designed to help us serve our customers while maintaining strict privacy and security standards. PBA is committed to protecting your privacy and will always be proactive in our effort to keep your information private.
PBA recognizes that protecting the privacy and security of the personal information we obtain about Plan participants is an important responsibility. This Privacy Statement generally describes our policy about how we treat that information. This Statement refers to PBA using the terms "we," "us," and "our."
Information we collect. We collect nonpublic personal information about Plan participants from the following sources:
- Information we receive from participants on applications or other forms.
- Information about participants' transactions with us, our affiliates or others.
Categories of information we disclose and parties to whom we disclose the information. We do not disclose any nonpublic personal information about Plan participants or former Plan participants to anyone, except as permitted by law.
Confidentiality and Security. We restrict access to nonpublic personal information about Plan participants to those employees and those affiliated and non-affiliated third parties who need to know that information to provide services to participants. We maintain physical, electronic and procedural safeguards that comply with Federal regulations to guard their nonpublic personal information.
The information we have about you is kept secure and confidential through multiple security features and procedures.
The confidential information you request from our Website or Mobile Applications can only be accessed with your personal password. It is your responsibility to keep your password confidential.
- Passwords are initially assigned to each user and may be changed by that user on the Website.
- If you do not know your password, please contact your Human Resource Department for instructions on how to securely reset or recover your password.
- Do not disclose your password to anyone. Our employees and associates will never ask you for your password.
- Never write your password on something others may see.
- Change your password immediately if you suspect someone has discovered it.
Information you submit through our Website, as well as the information we send back to you while you are visiting our Website, is protected while passing through the Internet using strong encryption ("scrambling" to make it incomprehensible) when necessary. Our software encrypts information, ensuring that Internet communications through our Website stay private and protected. You can verify that you are accessing a secure web page by examining the URL statement in your web browser. If you are accessing a secure web page then the URL begins with https:// instead of http://.
Your personal information is not permanently stored on our Web server. The information only resides on our Web server while you are viewing the information.
PBA has policies and procedures in place to limit access to your information to only those who have a need to view it.
There are locations in the public area of our Websites where you will have the opportunity to communicate with us by E-mail through the "Contact Us" Button. Messages traveling through the Internet using E-mail processes are subject to viewing, alteration, and copying by potentially anyone on the Internet. We encourage you to send confidential correspondence only when logged into our secure Website, or the postal service, or by using the telephone to speak directly to our Customer Service Representatives. We are not responsible for the security or confidentiality of communications you send to us through the Internet using the E-mail process. If you choose to communicate a confidential issue with us via E-mail we may also respond by E-mail. We will not use your E-mail address for any purpose other than to communicate vital information to you, or for password verification.
If you do not agree with all of the above policies, you have the right to exit. If you choose to remain connected to any of our Websites or Mobile Applications and proceed you hereby implicitly consent to the above policies.
PBA always welcomes your comments regarding this Statement of Privacy and Security. If you believe that PBA has not adhered to this Statement, please contact us by telephone, E-mail, or postal mail.
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