Effective Date: March 19, 2008

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.

Why have you been sent this Notice?
The Colorado School of Mines (CSM) Flexible Benefit Program is required under the Privacy Regulations of the Health Insurance
Portability and Accountability Act, 42 U.S.C. § 1320d – 1320d-8, and its implementing regulations, 45 C.F.R. Parts 160 and 164,
(HIPAA) to provide all employees eligible to participate in the Program with this notice of privacy practices. This notice concerns the
personal, protected health information (PHI) you have provided to the Program and any third party administrators in connection with the
flexible spending account provisions of the Program. CSM takes your privacy seriously. Your information will not be used or disclosed
without your written authorization, except as described in this notice or as otherwise permitted by Federal and State law. You may
revoke your authorization as provided by the HIPAA Privacy Regulations.

How do we use your information?
We restrict access to your PHI to those employees of CSM who need to know the information in order to provide services to you. CSM
uses your PHI without your written authorization for purposes of treatment, payment, or health care operations, which are explained
♦ Treatment is health care. For example, the Program may disclose PHI and confirm your program eligibility so that
treatment is provided to you.
♦ Payment is paying claims for health care and related activities. For example, the Program may disclose your PHI to
adjudicate claims and appeals.
♦ Health Care Operations is the administration and operation of the program. For example, the Program may disclose your
PHI to evaluate the quality of service that you receive.

With whom do we share your information? CSM may share your PHI, without your written authorization, with the vendors that assist
CSM in providing services to you for the Program. If we share your information, the vendors have an obligation not to disclose or use
your information for any other purpose, except as permitted by HIPAA and other law.

When else do we use or share your information?
There are limited circumstances when CSM is permitted or required to use or disclose your PHI without your written authorization.
These situations include:
♦ to keep you informed of health related benefits or services that may be of interest to you,
♦ public health purposes,
♦ medical
♦ use by medical examiners, coroners, funeral directors and organ donation organizations,
♦ judicial and administrative proceedings and law enforcement purposes,
♦ specialized government functions, such as military, intelligence and correctional activities,
♦ when otherwise required or permitted by law.

What are our duties?
CSM is required by law to:
♦ maintain the privacy of your PHI,
♦ provide this notice of our duties and privacy practices with respect to PHI,
♦ follow the procedures described in this notice,
♦ inform you that it reserves the right to change its privacy practices and the terms of this notice and to make the new notice
provisions effective for all PHI. Revised notices will be made available to you by posting on our website and notifying you
through campus e-mail.

What are your rights?
You have the right to:
♦ request that CSM restrict how it uses/discloses your PHI, CSM will consider your request but is not legally required to
♦ request that CSM communicate your PHI to you via alternative means or at alternate locations,
♦ inspect and copy your PHI (fees may apply),
♦ request additions or corrections to your PHI, CSM will consider your request but is not legally required to agree to it,
♦ receive an accounting of disclosures of your PHI made by CSM for reasons other than treatment, payment, health care
operations and disclosures to you or authorized by you,
♦ obtain a paper copy of this notice upon request,
♦ complain to CSM and to the Secretary of Health and Human Services in Washington D.C. if you believe your privacy
rights have been violated.

To contact us:
If you would like to exercise your rights, or if you feel that your privacy rights have been violated or if you need more information,
you may write to the Privacy Officer at the following address: Colorado School of Mines, Attn: Human Resources, 1500 Illinois Street,
Golden, CO, 80401 or call (303) 273-3250.

All complaints will be investigated and you will not be retaliated against for filing a complaint.

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