Notice of Privacy Practices
What you should know about your right to privacy
Notice of non-discrimination
We do not treat members differently because of sex, age, race, color, disability or national origin.
If you think you were treated unfairly because of your sex, age, race, color, disability or national origin, you can send a complaint to:
201 N. Harrison Street
Davenport IA, 52801
You must send the complaint within 60 days of the incident. We will send you a decision within 30 days. If you disagree with the decision, you have 15 days to appeal.
If you need help with your complaint, please call 1-844-693-4889, TTY/RTT 711. We are available Monday through Friday, 8 a.m. to 8 p.m. ET.
You can also file a complaint with the U.S. Dept. of Health and Human services.
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
Phone: Toll-free 1-800-368-1019, 1-800-537-7697 (TDD)
Mail: U.S. Department of Health and Human Services. 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201
1For purposes of the Language assistance services and this non-discrimination notice (“notice”), “We” refers to the entities listed in footnote 2 of the notice of privacy practices. Please note that not all entities listed are covered by this notice.
Medical Notice of Privacy Practices
Effective August 1, 2021
divvyDOSE is required by law to protect the privacy of your health information and to send you this notice. The notice explains how we may use information about you and when we can give out or “disclose” that information to others.
You have rights to your health information that are described in this notice. We are required by law to follow the terms of this notice.
The terms “information” and “health information” in this notice include any information we have that reasonably can be used to identify you and that relates to your physical or mental health condition, the health care you receive or the payment for such health care. We will comply with the requirements of applicable privacy laws related to notifying you in the event of a breach of your health information.
How We Use or Disclose Information
We must use or disclose your health information to provide information to:
- You or someone who has the legal right to act for you (your personal representative), to administer your rights as described in this notice; and
- The Secretary of the U.S. Department of Health and Human Services, if necessary, to make sure your privacy is protected.
We have the right to use and disclose health information for your treatment, to bill for your health care and to operate our business. For example, we may use or disclose your health information:
- For payment. We may use or disclose health information to obtain payment for your health care services. For example, we may disclose your health information to your health insurance company to collect payment for your pharmacy services.
- For treatment. We may use or disclose health information to aid in your treatment or the coordination of your care. For example, we may disclose information to treating physicians or others involved in your care, regarding possible drug interactions.
- For health care operations. We may use or disclose health information as needed to operate and manage our business activities related to providing and managing your health care. For example, we might analyze your information to determine ways to improve our services. We may also de-identify health information in accordance with applicable laws. After that information is de-identified, it is no longer subject to this notice and we may use it for any lawful purpose.
- To provide you information on health-related programs or products such as alternative medical treatments and programs about health-related products and services, subject to the limits of the law.
- For reminders. We may use or disclose health information to send you reminders about your care, such as prescription-refill reminders.
We may use or disclose your health information for the following purposes, under limited circumstances:
- As required by law. We may disclose information when required to do so by law.
- To persons involved with your care. We may use or disclose your health information to a person involved in your care or who helps pay for your care, such as a family member, when you are incapacitated or in an emergency, or when you agree or fail to object when given the opportunity. If you are unavailable or unable to object, we will use our best judgment to decide if the disclosure of information is in your best interest. Special rules apply regarding when we may disclose health information to family members and others involved in a deceased individual’s care. We may disclose health information to any persons involved, prior to the death, in the care or payment for care of a deceased individual, unless we are aware that doing so would be inconsistent with a preference previously expressed by the deceased.
- For public health activities such as reporting or preventing disease outbreaks. We may also disclose your information to the Food and Drug Administration (FDA) or persons under the jurisdiction of the FDA for purposes related to safety or quality issues, adverse events or to facilitate drug recalls.
- For reporting victims of abuse, neglect or domestic violence to government authorities that are permitted by law to receive such information, including social services or protective service agencies.
- To health oversight agencies for activities permitted by law, such as licensure, governmental audits, and fraud and abuse investigations.
- For judicial or administrative proceedings such as in response to a court order, search warrant or subpoena.
- For law enforcement purposes. We may disclose your health information to a law enforcement official for purposes such as providing limited information to locate a missing person or report a crime.
- To avoid a serious health or safety threat to you, another person, or the public. For example, disclosing information to public health agencies or law enforcement authorities, or in the event of an emergency or natural disaster.
- For specialized government functions such as military and veteran activities, national security and intelligence activities, and the protective services of the President and others.
- For workers’ compensation as permitted by, or to the extent needed to comply with, state workers’ compensation laws that govern job-related injuries or illness.
- For research purposes related to evaluating certain treatments or to prevent disease or disability, if the research study meets federal privacy law requirements.
- To provide information regarding decedents. We may disclose information to a coroner or medical examiner to identify a deceased person, determine a cause of death, or as authorized by law. We may also disclose information to funeral directors as necessary to carry out their duties.
- For organ procurement purposes. We may use or disclose information to people and organizations who procure, bank or transplant organs, eyes or tissue, to help with organ donations and transplants.
- To correctional institutions or law enforcement officials if you are an inmate of a correctional institution or under the custody of a law enforcement official, but only if necessary (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) for the safety and security of the correctional institution.
- To business associates that perform activities on our behalf or provide us with services if the information is necessary for such activities or services. Business associates are required, under contract and pursuant to federal law, to protect the privacy of your information and are not allowed to use or disclose any information other than as stated in our contract and permitted by law.
- Additional restrictions on use and disclosure. Certain federal and state laws may require special privacy protections that limit the use and disclosure of certain health information, including highly confidential information about you. Such laws may protect the following types of information:
- Alcohol and Substance Abuse
- Biometric Information
- Child or Adult Abuse or Neglect, including Sexual Assault
- Communicable Diseases
- Genetic Information
- Mental Health
- Minors’ Information
- Reproductive Health
- Sexually Transmitted Diseases
If a use or disclosure of health information described above in this notice is prohibited or materially limited by other laws that apply to us, it is our intent to meet the requirements of the more stringent law.
Except for the allowed and required uses and disclosures described in this notice, we will use and disclose your health information only with written authorization from you. This includes, except for limited circumstances allowed by federal privacy law, not using or disclosing psychotherapy notes about you, selling your health information to others, or using or disclosing your health information for certain promotional communications that are prohibited marketing communications under federal law, without your written authorization.
Once you authorize us to release your health information, we cannot guarantee that the recipient we gave the information to is obligated to protect and will not further disclose your information. You may take back or “revoke” your written authorization at any time in writing. This will not apply to uses and disclosures we have already acted upon based on your initial authorization. To find out how to take back your authorization, see our contact information in the section called “Exercising Your Rights.”
Your rights, with respect to your health information:
- You have the right to ask to restrict uses or disclosures of your information for treatment, payment, or health care operations. You also have the right to ask to restrict disclosures to family members or to others who are involved in your health care or payment for your health care. You must make a written request to restrict the use or disclosure of your information. See instructions in the “Making a Written Request” section. Please note that while we will try to honor your request, we are not required to agree to any restriction other than with respect to certain disclosures to health plans as further described in this notice.
- You have the right to request that we not send health information to health plans in certain cases if the health information is about a health care item or service for which you or a person on your behalf has paid us in full. You must make this request — either verbally or in writing — at the time you submit or call in your order. We will agree to all requests meeting the above criteria and submitted in a timely manner.
- You have the right to ask to receive confidential communications by asking us to send information by alternative means or at alternative locations — for example, to another address instead of your home address. You must make a written request to receive confidential communications or to cancel or change an earlier request. Please see the section called “Making a Written Request” for instructions. We will honor reasonable requests.
- You have the right to ask to make changes to certain health information we maintain about you, such as medical records and billing records, if you believe the health information about you is wrong or incomplete. You must make a written request to change your information and explain your reason(s) for the requested change(s). Please see the “Making a Written Request” section for instructions. If we deny your request, you may have a statement of your disagreement added to your health information.
- You have the right to see and obtain a copy of certain of your health information maintained by us, such as your medical records and billing records. If we maintain a copy of your health information electronically, you will have the right to request that we send a copy of your health information in an electronic format to you. You can also request that we provide a copy of your information to a third party that you name. In some cases, you also may receive a summary of this health information. You must make a written request to inspect and obtain a copy of your health information. Please see the section called “Making a Written Request” for instructions. In certain cases, we may deny your request to inspect and copy your health information. If we deny your request, you may have the right to have the denial reviewed. We may charge a reasonable fee for any copies.
- You have the right to receive a listing of certain disclosures of your information made by us during the six years before your request. This list will not include disclosures of information made: (i) for treatment, payment, and health care operations purposes; (ii) to you or people you authorized; (iii) to correctional institutions or law enforcement officials; and (iv) other disclosures for which federal law does not require us to keep track of. You must submit a written request for a list of disclosures. Please see the “Making a Written Request” section for instructions.
- You have the right to request a paper copy of this notice at any time. You may ask for a copy of this notice at any time by calling our divvyDOSE customer service advocates at the number printed on your ID card. Even if you have agreed to receive this notice electronically, you can still request additional paper copies of this notice. You may also view and/or print a copy of this notice at our website, www.divvyDOSE.com
Exercising your rights
Making a written request. You must submit a written request to exercise certain rights. For your convenience, we have created Individual Rights Request forms for you to use to ensure that we properly document and process your request. To obtain a form either:
- Go to optumrx.com, scroll to Forms at the bottom of the page. Or,
- Log into optumrx.com account and select Information Center > Programs & forms
- Contact customer service at the number printed on your ID card and have us mail a form to you.
Then, mail or fax your completed Individual Rights Request form to the Privacy Office. The contact information is in the “Questions About This Notice or to File a Complaint” section.
Designating a Personal or Authorized Representative so that OptumRx may discuss and give out your health information to a third party named by you, you must send to us written material that names that person, such as:
- A legal document granting personal representation such as health care power of attorney, guardianship, or conservatorship. Or,
- A completed Authorization To obtain a form:
— Go to www.optumrx.com, scroll to Forms at the bottom of the page. Or,
— Log into your www.optumrx.com account and select Information Center > Programs & forms
— Contact customer service at the number printed on your ID card and have us mail a form to you.
Questions about this notice or to file a complaint. If you have questions about this notice, please contact the Privacy Office. Also, if you believe your privacy rights have been violated, you may file a complaint with us. You may also notify the Secretary of the U.S. Department of Health and Human Services of your complaint. We will
not take any action against you for filing a complaint.
- Contact us by mail or phone:
Attn: Privacy Office
2300 Main Street
Irvine, CA 92614
Acknowledgment of receipt of OptumRx notice of privacy practices
By signing this document, I state that I have received a copy of the OptumRx notice of privacy practices.
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- Keep the notice of privacy practices brochure for your records?
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Mail in your acknowledgement of receipt:
You can return this acknowledgment of receipt to the following address for our records:
PO Box 9040
Carlsbad, CA 92018-9040
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