Fit4Me Challenge!

HIPAA NOTICE OF PRIVACY PRACTICES

Protecting Your Privacy and Servicing Your Needs

Effective January 2008

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

If you have any questions about this notice, please contact: Fit4Me Challenge LLC, PO Box 665, Edwardsville, IL. 62025, (618) 954-8387

OUR PLEDGE REGARDING PROTECTED HEALTH INFORMATION:

We at the Fit4Me Challenge understand that protected health information about you and your health is personal. We are committed to protecting this information. This Notice applies to all of the records and forms of your participation generated by the Fit4Me Challenge whether made by personnel/staff or your personal doctor.

This Notice will tell you about the ways in which we may use and disclose protected health information about you. We also describe your rights and certain obligations we have regarding the use and disclosure of protected health information. The law requires us to:

make sure that protected health information that identifies you is kept private;
notify you about how we protect protected health information about you;
explain how, when and why we use and disclose protected health information;
follow the terms of the Notice that is currently in effect.

We are required to follow the procedures in this Notice. We reserve the right to change the terms of this Notice and to make new notice provisions effective for all protected health information that we maintain by:

posting the revised Notice on our website;
making copies of the revised Notice available upon request;

HOW WE MAY USE AND DISCLOSE PROTECTED HEALTH INFORMATION ABOUT YOU

The following categories describe different ways that we use and disclose protected health information without your written authorization.

For Participation in the Challenge. We may use protected health information about you to provide you with, coordinate or manage your participation in this event. We may disclose protected health information about you to our expert team or other Fit4Me Challenge personnel/staff. We may use and disclose protected health information to tell you about or recommend possible treatment options or alternatives or health-related benefits or services that may be of interest to you.

For Health Care Operations. We may use and disclose protected health information about you for Fit4Me Challenge operations, such as assessments, case management, coordination of participation, customer services and other activities. These uses and disclosures are necessary to run this challenge and make sure that all of our participants receive a quality experience.

Subject to applicable state law, in some limited situations the law allows or requires us to use or disclose your health information for purposes beyond treatment, payment, and operations. However, some of the disclosures set forth below may never occur.

As Required By Law. We will disclose protected health information about you when required to do so by federal, state or local law.

Health Risks We may disclose your health information to researchers when their research has been approved by an institutional review board or privacy board that has reviewed the research proposal and established protocols to ensure the privacy of your information.

Judicial and Administrative Proceedings If you are involved in a lawsuit or dispute, we may disclose your information in response to a court or administrative order. We may also disclose health 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, either by us or the requesting party, to tell you about the request or to obtain an order protecting the information requested

Business Associates. We may disclose information to business associates who perform services on our behalf (such as billing companies) however, we require them to appropriately safeguard your information.

Public Health. As required by law, we may disclose your protected health information to public health or legal authorities charged with preventing or controlling disease, injury, or disability.

To Avert a Serious Threat to Health or Safety We may use and disclose protected health information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person.

Health Oversight Activities. We may disclose protected health information to a health oversight agency for activities authorized by law. These activities include audits, investigations, and inspections, as necessary for licensure and for the government to monitor the health care system, government programs, and compliance with civil rights laws.

Law Enforcement. We may release protected health information as required by law, or in response to an order or warrant of a court, a subpoena, or an administrative request. We may also disclose protected health information in response to a request related to identification or location of an individual, victims of crime, decedents, or a crime on the premises.

Organ and Tissue Donation. Special Government Functions. If you are a member of the armed forces, we may release protected health information about you if it relates to military and veterans activities. We may also release your protected health information for national security and intelligence purposes, protective services for the President, and medical suitability or determinations of the Department of State. Coroners, Medical Examiners, and Funeral Directors. We may release protected health information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also disclose protected health information.

Coroners, Medical Examiners, and Funeral Directors We may release protected health information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also disclose protected health information to funeral directors consistent with applicable law to enable them to carry out their duties.

Correctional Institutions and Other Law Enforcement Custodial Situations If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release protected health information about you to the correctional institution or law enforcement official as necessary for your or another person's health and safety.

Worker's Compensation. We may disclose information as necessary to comply with laws relating to worker's compensation or other similar programs established by law.

Food and Drug Administration. We may disclose to the FDA, or persons under the jurisdiction of the FDA, protected health information relative to adverse events with respect to drugs, foods, supplements, products and product defects, or post marketing surveillance information to enable product recalls, repairs, or replacement.

YOU CAN OBJECT TO CERTAIN USES AND DISCLOSURES

Unless you object, or request that only a limited amount or type of information be shared, we may use or disclose protected health information about you in the following circumstances:

We may share with a family member, relative, friend or other person identified by your protected health information directly relevant to that person's involvement in your care or payment for your care. We may also share information to notify these individuals of your location, general condition or death.
We may share information with a public or private agency (such as the American Red Cross) for disaster relief purposes. Even if you object, we may still share this information if necessary for the emergency circumstances.

If you would like to object to use and disclosure of protected health information in these circumstances, please call or write to our contact person listed on page 1 of this Notice.

YOUR RIGHTS REGARDING PROTECTED HEALTH INFORMATION ABOUT YOU.

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

Right to Inspect and Copy. You have the right to inspect and copy protected health information that may be used to make decisions about you, you must submit your request in writing to Fit4Me Challenge LLC, Lorraine Huntley, PO Box 665, Edwardsville, IL. 62025. 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, and we will respond to your request no later than 30 days after receiving it. There are certain situations in which we are not required to comply with your request. In these circumstances, we will respond to you in writing, stating why we will not grant your request and describe any rights you may have to request a review of our denial.

Right to Amend. If you feel that protected health information we have about you is incorrect or incomplete, you may ask us to amend or supplement the information. To request an amendment, your request must be made in writing and submitted to: Fit4Me Challenge LLC, Lorraine Huntley, PO Box 665, Edwardsville, IL. 62025. In addition, you must provide a reason that supports your request. We will act on your request for an amendment no later than 60 days after receiving the request.

We may deny your request for an amendment if it is not in writing or does not include a reason to support the request, and will provide a written denial to you. In addition, we may deny your request if you ask us to amend information that:

Was not created by us, unless the person or entity that created the information is no longer available to make the amendment;
Is not part of the protected health information kept by the Fit4Me Challenge, LLC;
Is not part of the information which you would be permitted to inspect and copy; or
We believe 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 the disclosures we made of protected health information about you.

To request this list or accounting of disclosures, you must submit your request in writing to: Fit4Me Challenge LLC, Lorraine Huntley, PO Box 665, Edwardsville, IL. 62025. The first list you request within a 12-month period will be free. For additional lists, we will charge you for the costs of providing the list. We are required to provide a listing of all disclosures except the following:

For your participation
For collection of payment
For operational needs
Made to or request by you, or that you authorized
Occurring as a byproduct of permitted use and disclosures
For national security or intelligence purposes or to correctional institutions or law enforcement regarding inmates
As part of a limited data set of information that does not contain information identifying you

Right to Request Restrictions You have the right to request a restriction or limitation on the protected health information we use or disclose about you for your participation in the challenge. We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment, the disclosure is to the Secretary of the Department of Health and Human Services. To request restrictions, you must make your request in writing to: Fit4Me Challenge LLC, Lorraine Huntley, PO Box 665, Edwardsville, IL. 62025.

Right to Request Confidential Communications You have the right to request that we communicate with you 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: Fit4Me Challenge LLC, Lorraine Huntley, PO Box 665, Edwardsville, IL. 62025. We will accommodate all reasonable requests.

Right to a Paper Copy of This Notice You have the right to a paper copy of this Notice at any time by contacting: Fit4Me Challenge LLC, Lorraine Huntley, PO Box 665, Edwardsville, IL. 62025.

OTHER USES AND DISCLOSURES. We will obtain your written authorization before using or disclosing your protected health information for purposes other than those provide for above (or as otherwise permitted or required by law). You may revoke this authorization in writing at any time. Upon receipt of the written revocation, we will stop using or disclosing your information, except to the extent that we have already taken action in reliance on the authorization.

YOU MAY FILE A COMPLAINT ABOUT OUR PRIVACY PRACTICES: If you believe your privacy rights have been violated, you may file a complaint with the Fit4Me Challenge LLC, Lorraine Huntley, PO Box 665, Edwardsville, IL. 62025 or file a written complaint with the Secretary of the Department of Health and Human Services. A complaint to the Secretary should be filed within180 days of the occurrence or action that is the subject of the complaint. If you file a complaint, we will not take any action against you or change your involvement in the challenge in any way.