CROFT, LLC MEDICAL AND DENTAL PLAN

NOTICE OF PRIVACY PRACTICES

Effective April 14, 2004

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. THIS NOTICE GIVES YOU INFORMATION REQUIRED BY LAW about the duties and privacy practices of the following health plans sponsored by Croft, LLC to protect the privacy of your medical information:  Croft, LLC Employee Medical and Dental Plans (collectively referred to hereinafter as the “Plan” or the “Plans”).

The Plans provide health and/or dental benefits to you as described in your summary plan descriptions.  Each Plan receives and maintains your medical information in the course of providing the respective health and/or dental benefits to you.  Each Plan hires business associates to help it provide these benefits to you.  These business associates also receive and maintain your medical information in the course of assisting the respective Plan.  The Plans are sponsored by Croft, LLC (the “Plan Sponsor”).

THE EFFECTIVE DATE OF THE NOTICE IS APRIL 14, 2004.  The Plans are required to follow the terms of this notice until it is replaced.  Each Plan reserves the right to change the terms of this notice at any time.  If one or both of the Plans make changes to this notice, the Plans reserve the right to make the new changes apply to all your medical information maintained by the Plans before and after the effective date of the new notice. 

Purposes for which the Plans May use or Disclose Your Medical Information Without Your Consent or Authorization

Each Plan may use and disclose your medical information for the following purposes:

• Health Care Providers’ Treatment Purposes.  For example, each Plan may disclose your medical information to your doctor, at the doctor’s request, for your treatment by him.

• Payment.  For example, each Plan may use or disclose your medical information to pay claims for covered health care services or to provide eligibility information to your doctor when you receive treatment.  Each Plan may also use and disclose your medical information to another covered entity or health care provider for the payment activities of the entity that receives your medical information.

• Health Care Operations.  For example, each Plan may use or disclose your medical information (i) to conduct quality assessment and improvement activities, (ii) for underwriting, premium rating, or other activities relating to the creation, renewal or replacement of a contract of health insurance, (iii) to authorize business associates to perform data aggregation services, (iv) to engage in care coordination or case management, and (v) to manage, plan or develop its business.  Each Plan may also disclose your medical information to another covered entity for the limited health care operations activities and health care fraud and abuse compliance activities of the entity that receives your medical information.

• Organized Health Care Arrangement.  Because the same Plan Sponsor sponsors the Plans, the Plans are deemed to be participants in an organized health care arrangement (the “Arrangement”).  As such, the Plans may share your medical information with each other as needed for the purposes of treatment, payment or health care operations (described above) relating to the Arrangement.

• Health Services.  Each Plan may use your medical information to contact you to give you information about treatment alternatives or other health-related benefits and services that may be of interest to you.  Each Plan may disclose your medical information to its business associates to assist the Plan in these activities.

• As required by Law.  For example, each Plan must allow the U.S. Department of Health and Human Services to audit Plan records.  Each Plan may also disclose your medical information as authorized by and to the extent necessary to comply with workers’ compensation or other similar laws.

• To Business Associates.  Each Plan may disclose your medical information to business associates the Plan hires to assist the Plan.  Each business associate of the Plans must agree in writing to ensure the continuing confidentiality and security of your medical information.

• To Plan Sponsor.  The Plans may disclose to the Plan Sponsor, in summary form, claims history and other similar information.  Such summary information does not disclose your name or other distinguishing characteristics.  The Plans may also disclose to the Plan Sponsor the fact that you are enrolled in, or disenrolled from the Plans.  The Plans may disclose your medical information to the Plan Sponsor for Plan administrative functions that the Plan Sponsor provides to the Plans if the Plan Sponsor agrees in writing to ensure the continuing confidentiality and security of your medical information.  The Plan Sponsor must also agree not to use or disclose your medical information for employment-related activities or for any other benefit or benefit plans of the Plan Sponsor.

Each Plan may also use and disclose your medical information as follows:

• To comply with legal proceedings, such as a court or administrative order or subpoena.

• To law enforcement officials for limited law enforcement purposes.

• To a family member, friend or other person, for the purpose of helping you with your health care or with payment for your health care, if you are in a situation such as a medical emergency and you cannot give your agreement to the Plan to do this.

• To your personal representatives appointed by you or designated by applicable law.

• For research purposes in limited circumstances.

• To a coroner, medical examiner, or funeral director about a deceased person.

• To an organ procurement organization in limited circumstances.

• To avert a serious threat to your health or safety or the health or safety of others.

• To a governmental agency authorized to oversee the health care system or government programs.

• To federal officials for lawful intelligence, counterintelligence and other national security purposes.

• To public health authorities for public health purposes.

• To appropriate military authorities, if you are a member of the armed forces.

Potential Impact of State Law

In some situations, neither the HIPAA Privacy Rules nor ERISA will preempt (or take precedence over) state privacy laws that give you greater protections.  As a result, the privacy laws of a particular state might impose a privacy standard under which we will be required to operate.  If an applicable state’s privacy laws are not preempted by the HIPAA Privacy Rules or by ERISA, we will follow that particular state’s privacy law.

Users and Disclosures with Your Permission

The Plans will not use or disclose your medical information for any other purposes unless you give the Plans your written authorization to do so.  If you give the Plans written authorization to use or disclose your medical information for a purpose that is not described in this notice, then in most cases you may revoke it in writing at any time.  Your revocation will be effective for all your medical information the Plans maintain, unless the Plans have taken action in reliance on your authorization.

Your Rights

You may make a written request to each Plan to do one or more of the following concerning your medical information that the Plan maintains:

• To put additional restrictions on the Plan’s use and disclosure of your medical information.  The Plan does not have to agree to your request.

• To communicate with you in confidence about your medical information by a different means or at a different location than the Plan is currently doing.  The Plan does not have to agree to your request unless such confidential communications are necessary to avoid endangering you and your request continues to allow the Plan to collect in confidence.  Even though you requested that we communicate with you in confidence, the Plan may give subscribers cost information.

• To see and get copies of your medical information.  In limited cases, the Plan does not have to agree to your request. 

• To correct your medical information.  In some cases, the Plan does not have to agree to your request.

• To receive a list of disclosures of your medical information that the Plan and its business associates made for certain purposes for the last 6 years (but not for disclosures before April 14, 2004).

• To send you a paper copy of this notice if you received this notice by e-mail or the Internet.

Complaints

If you believe your privacy rights have been violated by the Plans, you have the right to complain to the Plans or to the Secretary of the U.S. Department of Health and Human Services.  You may file a complaint with the Plans at our Contact Office (below).  We will not retaliate against you if you choose to file a complaint with the Plans or with the U.S. Department of Health and Human Services.

Contact Office

To request additional copies of this notice or to receive more information about our privacy practices or your rights, please contact us at the following Contact Office:

Croft, LLC

Privacy Office

Vic Donati

(601) 684-6121 x 236