UPHS_Enrollment_Flipbook_Print_Version

Restrictions on Use and Disclosure of Your Protected Health Information. You have the rightto request restrictions on certain permitted uses and disclosures of your protected healthinformation for treatment, payment or health care operations, though we cannot agree to restrict orlimit any use or disclosure that is required by law. We will consider your request, but are not legallyrequired to agree to it. However, we will attempt to accommodate reasonable requests whereappropriate and if we agree to accommodate your request, we will abide by it. We retain the rightto terminate an agreed-to restriction if we believe such termination is appropriate. In the event of atermination by us, we will notify you of such termination. Requests for restriction(s) must be madein writing and signed by you or your personal representative.Confidential Communications. You have the right to request to receive communicationsregarding your protected health information from us by alternate means or at alternate locations.You must request such confidential communication in writing. We will attempt to accommodate allreasonable requests.Paper Copy of Notice. You retain the right to obtain a paper copy of this Notice of PrivacyPractices, even if you have requested such copy by e-mail or other electronic means.Complaints. If you believe your privacy rights have been violated, you can file a complaint withEmployee Benefits by calling 215-615-2675. You may also file a complaint with the Secretary ofthe U.S. Department of Health and Human Services in Washington D.C. There will be no retaliationfor filing a complaint.Women’s Health and Cancer Rights Act NoticeThe Women’s Health and Cancer Rights Act of 1998 requires that all UPHS medical plans coverthe following medical services in connection with coverage for a mastectomy: reconstruction of thebreast on which the mastectomy has been performed; surgery and reconstruction of the otherbreast to produce a symmetrical appearance; and prostheses and physical complications in allstages of mastectomy, including lymphedemas.These services shall be provided in a manner determined in consultation with the attendingphysician and the patient. Coverage for these medical services are subject to applicabledeductibles and coinsurance amounts.Notice of Opportunity to Enroll in connection with Extension of DependentCoverage to Age 26Individuals whose coverage ended, or who were denied coverage (or were not eligible forcoverage), because the availability of dependent coverage of children ended beforeattainment of age 26, are eligible to enroll in the University of Pennsylvania Health System’sgroup health plan or health insurance coverage. Individuals may request enrollment for suchchildren for 30 days from the date of notice. Enrollment will be effective retroactively toJuly 01, 2011. For more information contact the Corporate Employee Benefits Department at215-615-2675, option #4.