Ebenezer Society Group Health Plans


Effective Date: 01/01/06




A message from Ebenezer Society:

As an employer and a health care provider, Ebenezer Society takes its responsibility to ensure privacy seriously. Ebenezer Society sponsors several self-funded group health plans for its employees. Federal regulations regarding the privacy of health information require that Ebenezer Society protect the health and claims information of its covered employees and family members. As the sponsor of these health plans, we have documented how we will use and protect the health information and billing information associated with the health plans. The following information is Ebenezer Society's group health plans' Notice of Privacy Practices. It describes how Ebenezer Society uses and protects your information and it also includes a description of your rights related to your health and billing information.

We are required to provide you with this information; no action is required on your part. If you have any questions about this notice, please contact the Privacy Official in the Ebenezer Society privacy office at 612-874-3474.

This notice is for the employees of Ebenezer Society and Ebenezer Realty Service Company. Collectively for purposes of this notice, these entities co-sponsor various employee benefit plans for the benefit of the employees. Some of these plans are self-insured plans and fall under the definition of Group Health Plans under the Health Insurance Portability and Accountability Act (HIPAA) Privacy Regulations. The regulations address the privacy requirements related to the use of protected health information by the Group Health Plans themselves. Ebenezer Society has always worked hard to protect the privacy of your health information. The HIPAA Privacy Regulations require that the Group Health Plans send you this notice explaining how they use, disclose and protect your medical or health information.

This notice does not apply to Ebenezer Society in its capacity as a provider of health care services. A separate Notice of Privacy Practices applies to Ebenezer Society in its capacity as a health care provider and may be obtained on the Fairview web site at, or by contacting the Ebenezer Society facility where you receive care.

For purposes of this notice, your "medical information" or "health information" is information that identifies you and relates to your past, present or future physical or mental health or condition; the provision of health care to you; or the past, present, or future payment for health care furnished to you. The terms "we" or "our" in this notice refers to the Group Health Plans listed below.

One way to view Ebenezer Society is to divide it into three parts: Ebenezer Society the Provider, Ebenezer Society the Employer, and Ebenezer Society the Group Health Plan. Long before HIPAA was created, Ebenezer Society recognized these three separate functions and created polices, procedures, segregation of duties, employee training and other controls so that the medical or health information received by one of these functions is not shared with the other functions in violation of the law. These protections are in place for all of Ebenezer Society's benefit plans, not just the nine plans listed above.

For example, Ebenezer Society's Human Resource Departments cannot access the medical record created for you as a Ebenezer Society patient without your authorization. In addition, the Ebenezer Society Benefits Department and EAP Department records and processes are separate from each other and from the rest of the Human Resources Department records and processes.


We are required by applicable federal law to maintain the privacy of your health information. Federal law (HIPAA) requires us to provide you with this notice of our legal duties and privacy practices with respect to your medical information. If you have any questions about this notice, please contact the Ebenezer Society Privacy Official at 612-874-56473474.

We are required to abide by the terms of this Notice of Privacy Practices. This Notice of Privacy Practices becomes effective April 14, 2003 and will remain in effect until we replace it. We reserve the right to change this Notice of Privacy Practices at any time and for any reason. We reserve the right to make the revised or changed notice effective for health information we already have about you as well as any information we receive in the future. A copy of our most current Notice of Privacy Practices will be posted in Ebenezer Society Human Resources Departments, on the Ebenezer Society intranet - intranet.Ebenezer, and on our public website -


Because these group health plans are all sponsored by Ebenezer Society, they are a part of an organized health care arrangement. . Except for the Employee Assistance Program, this means that these group health plans may share your health information with each other as needed for the purposes of payment and health care operations, as described below. The Employee Assistance Program, however, does not share health information with the other group health plans.


The following categories describe different ways that we use and disclose medical information. For each category of uses or disclosures we will explain what we mean and give an example. All of the ways we are permitted to use and disclose information will fall within one of the categories. However, not every specific use or disclosure in a category will be listed.


Our third party administrators (Delta Dental, and PreferredOne and Fairview Health Services) will use your health information to pay claims from providers for any treatment and services provided to you that are covered by the Group Health Plans. The information on or accompanying a claim may include information that identifies you, as well as your diagnosis, procedures, and supplies used. The Fairview Employee Service Center will use the health information and claims information you submit to process reimbursement from your pre-tax medical spending account.

Payment also includes using or disclosing health information to make determinations on disputed claims, to determine eligibility for benefits, and to coordinate benefits. For example, claims information may be shared with the responsible party / guarantor of the claim as necessary to obtain payment on a claim.

Payment also includes making determinations regarding cost sharing and responsibility for paying a claim or obtaining reimbursement, examining health necessity, obtaining payment under stop loss insurance, and conducting utilization review. For example, you may have a question regarding the payment of a claim. We may need to access your claim information to assist in answering questions necessary to ensure the payment of the claim.

When we say we use your health information for payment purposes, the "we" we are talking about is our third party administrators or selected employees in Ebenezer Society’s benefit department.

The Employee Assistance Program does not pay claims so it does not use your health information for payment purposes.

Health Care Operations We may use and disclose health information for our business functions and activities. Our business functions and activities include, among other things, engaging in care coordination and case management, rating risk, determining premiums, auditing and detecting fraud and abuse and conducting quality assessments and improvement activities. These uses and disclosures are necessary to facilitate the operation of the group health plans and to make sure that all of our members receive quality care.

For example, for our PreferredOne health plans, if you are diagnosed with a chronic disease, your health information may be used for purposes of disease management and you may be contacted by our the disease management group about treatment information.

Plan Sponsor

Health information may be disclosed to or used by Ebenezer Society, as the Plan Sponsor of the group health plans as described in this document. Ebenezer Society will not use or disclose your health information maintained by its Group Health Plans for any employment-related functions. For a more detailed explanation of the limited ways that Ebenezer Society, as Plan Sponsor, may use or disclose your health information when providing plan administration functions (with the exception of EAP which does not disclose PHI to the plan sponsor), you should refer to the plan document applicable to each group health plan.

For example, protected health information would be given to the Ebenezer Society as a plan sponsor for purposes of making a determination of claims payment for large catastrophic claims.

Business Associates

To administer the plans we may hire third parties such as third-party administrators, auditors, attorneys, consultants and the like. When we contract for services to assist in our business operations, health information may be disclosed to or used by our business associates so that they can perform their jobs. To protect your health information, we enter into a contract that limits each business associate's ability to use and disclose health information and requires them to appropriately safeguard the health information of plan participants.

For example, PreferredOne, Delta Dental, ClearScript, and National Pharmaceutical Services are business associates of some of our Group Health Plans and receive your health information to perform the services offered by the Group Health Plans.

Communication with Your Family

We may disclose health information to a family member, other relative, person authorized by law, close personal friend or any other person you identify as involved in your care or payment related to your care. Except as authorized by law, we only do this when we understand that you want us to communicate with these people. Only health information relevant to that person’s involvement in your care or payment related to your care will be disclosed. You can restrict this activity at any time. The Employee Assistance Program only communicates with your family members with your authorization or if required by law. If you are incapacitated or in the event of an emergency, we will exercise our professional judgment to determine whether a disclosure of this type is in your best interest.

Health Education

We (or our Business Associates) may use health information to contact you about treatment alternatives or other health related benefits and services that may be of interest to you. This does not apply and would not be done for those who have received services from the Employee Assistance Program.

Judicial or Administrative Proceedings

We will disclose health information in response to a court or administrative order, and in response to subpoena, discovery request or other lawful process if certain conditions are met and we receive the required assurances.

As Required by Law Your health information may be disclosed if such disclosure is required by law (e.g., to federal governmental agencies, such as the Department of Health and Human Services for the purpose of determining compliance with HIPAA privacy rules; or to other appropriate authorities to lessen a serious and imminent threat to the health or safety of you or the public, including abuse of a vulnerable adult or child, subject to certain limitations and conditions).

Parents of Minors

Health Information of a minor child, in most cases, will be disclosed to a parent or guardian of that minor, subject to certain limitations imposed by Minnesota law.

Workers’ Compensation

Your health information may be used to the extent authorized by and to the extent necessary to comply with laws relating to Workers’ Compensation or other similar programs. EAP would not release any information without your written authorization.

Your Authorization
We are required to disclose your health information to you upon your request as described in the "Your Rights Regarding Health Information" section below. To use or disclose your health information for reasons other than the categories listed above, we must obtain a signed written authorization from you. You may provide us with written authorization to use or disclose your health information to anyone for any purpose specified in the authorization. You may revoke such authorization in writing at any time. You should be aware, however, that such revocation will not impact any uses or disclosures that occurred while your authorization was in effect.


This section describes your rights regarding the health information we maintain about you. All requests relating to any of the rights described in this section must be made in writing. Unless otherwise specified, your written requests relating to the Employee Assistance Program must be submitted to:

Ebenezer Society
Benefits Department Manager
2450 Riverside Avenue South2722 Park Avenue
Minneapolis, MN, 55454 55407

Unless otherwise specified, your written requests relating to the Employee Assistance Program must be submitted to:

Fairview Health Services
Employee Assistance Program Department Manager
2450 Riverside Avenue South
Minneapolis, MN, 55454

Right to Amend
If you feel that health information we have about you is incorrect or incomplete; you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by or for us. Your request must include a reason to support the requested amendment. You will be notified in writing if your request is denied. If your request is denied, you have the right to submit a written statement disagreeing with the denial, which will be appended or linked to the health information in question.

Right to an Accounting of Disclosures

You have the right to request a list of the disclosures of your health information, if any, our Business Associates or we have made other than for treatment, payment, health care operations and certain other limited purposes. Your request must state a time period, which may not be longer than six years and may not include dates before April 14, 2003. The first list you request within a 12-month period will be free. For additional lists, we may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.

Right to Request Restrictions
You have the right to request a restriction or limitation on the health information we use or disclose about you for treatment, payment or health care operations. Federal law states that 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. In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit our use, disclosure or both; and (3) to whom you want the limits to apply, for example, disclosures to your spouse.

Right to Request Confidential Communications

You have the right to request that we communicate with you about health matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.

Right to Inspect and Copy

You have the right to inspect and copy your health information. 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. We may deny your request to inspect and copy health information in certain very limited circumstances. If you are denied access to health information, you will receive a written denial and you may request that the denial be reviewed. Another individual chosen by us will review the denial of your request. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review.

To inspect or request copies of claim information for Group Health Plans administered by PreferredOne, direct your request to:

PreferredOne Customer Service

Metro Area: 763-847-4470
Toll Free: 1-800-558-5185
Web Site:


To inspect or request copies of claim information for the Group Health Plans administered by Delta Dental, direct your request to:

Delta Dental Plan of Minnesota
Customer Service Department
PO Box 330
Minneapolis MN 55440-0330
Metro Area: 651-406-5916
Toll Free: 1-800-553-9536

To inspect or request copies of claim information for other Group Health Plans (EAP and Pre-Tax Medical Spending Account or EAP), refer to the contact information listed in the previous section entitled "Your rights regarding your health information".

Right to a Paper Copy of This Notice
You may request a paper copy of this notice at any time, even if you have agreed to receive this notice electronically. You may obtain a copy of this notice on our intranet website, intranet.Ebenezer, or on our public website,

Ebenezer Society
Corporate Privacy Office
2722 Park Avenue
Minneapolis, MN 55407


Ebenezer Society
Corporate Privacy Office
2722 Park Avenue
Minneapolis, MN 55407


If you believe your privacy rights have been violated; you may file a complaint with us or with the Secretary of the Department of Health and Human Services. You may call the Ebenezer Society Privacy Official at 612-672-5647 to discuss your complaint, ask questions or obtain the contact information for the Department of Health and Human Services. You will not be penalized for filing a complaint. All complaints made to us must be in writing and sent to: To obtain a paper copy of this notice, you may contact:


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