This notice describes how health information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

Effective Date: August 1, 2014

If you have any questions about this notice, please contact the Mainstay Life Services (MLS) Compliance Officer at 412-344-3640 or in writing at:

Compliance Officer
Mainstay Life Services
200 Roessler Road
Pittsburgh, PA 15220

We create a record of the care and services you receive at MLS to provide you with quality care and to comply with certain legal requirements. This notice will tell you about the possible ways in which we may use and disclose your health information from this record.

We are required by the Health Insurance Portability and Accountability Act of 1996, and the Health Information Technology for Economic and Clinical Health Act (found in Title XII of the American Recovery and Reinvestment Act of 2009, collectively referred to as “HIPAA” laws to:

  • Make sure that health information that identifies you is kept private;
  • Give you this notice of our legal duties and privacy practices with respect to health information about you; and
  • Follow the terms of the notice that is currently in effect.Please read this Notice of Privacy Practices thoroughly. It describes how we will use and protect your information and your rights and certain obligations we have regarding the use and disclosure of health information.

Our pledge regarding health information

Any information you share with staff and programs of MLS is important to us, and we pledge to keep it as confidential as possible. This rule applies to all employees, programs, and services operated by MLS.

By law there are some exceptions to this rule, and these are listed below. With the exception of these items, we pledge to maintain maximum confidentiality. Any releases of information permitted by HIPAA which are prohibited by Federal and State regulations and law continue to be prohibited.

  1. To Improve the Quality of Your Care
    We may use health information about you to provide you with other clinical or health services. We may disclose health information about you to doctors, nurses, therapists, staff, or others who are involved in taking care of you at MLS. For example, if you are referred to another program within MLS, your new provider and/or support staff will know about your needs and goals without having to ask you to repeat your story.We may also disclose health information about you to physicians, other practitioners and providers, MLS affiliates, and other health care facilities outside MLS for their use in treating you.
  2. To Improve the Internal Operations of Our Company
    We may use and disclose clinical or identifying information about you to improve internal operations. These uses and disclosures are necessary to run the organization and ensure that all of the individuals we serve receive quality care. For example, we may use information to review our care and services and to evaluate the performance of our staff and programs in caring for you. We may also provide minimal information to support staff to assist in scheduling or answering your calls and directing you to the staff you need. We may contact you as a reminder that you have an appointment for treatment or health services.Additionally, we may use and disclose health information to tell you about health-related benefits or services that may be of interest to you. We also believe that friends or family members may be helpful to you in reaching your goals. Where you indicate to us in writing that you want them to have access to information, we will talk to them and release information as authorized. Only persons you indicate will have this type of access.
  3. To Your Insurance or Responsible Party to Receive Payment
    Medicaid or your insurance carrier will need to know some basic detail about your condition and the services provided. Worker’s Compensation and military insurances may have special needs for information. This information is limited by state and federal law, and we will provide them the minimal necessary information when we receive your written approval at the time of admission to bill your insurer and provide this information.
  4. To Our Business Associates
    We may disclose your health information to our business associates and allow them to create, use and disclose your health information to perform their job. For example, we may disclose your health information to an outside billing company that assists us in billing insurance companies.
  5. Where There is a Serious Threat to Health or Safety
    We may use and disclose 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. Any disclosure, however, would only be to someone able to help prevent the threat.
  6. As Required by Law
    We will disclose health information about you when required to do so by federal, state, or local law. For example, if you are involved in a lawsuit or a legal dispute, we may disclose health information about you in response to a court or administrative order, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.We may release health information if asked to do so by a law enforcement official:

    1. in response to a court order, subpoena, warrant, summons, or similar process;
    2. to identify or locate a suspect, fugitive, material witness, or missing person;
    3. about the victim of a crime, if, under certain limited circumstances, we are unable to obtain theperson’s agreement;
    4. about a death we believe may be the result of criminal conduct;
    5. about criminal conduct at MLS; and
    6. in emergency circumstances to report a crime, the location of the crime or victims, or the identity,description, or location of the person who committed the crime. Also we may release health information about you to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.
    7. to identify a deceased person or to determine a cause of death, we may disclose information to a coroner, medical examiner, and funeral directors (as necessary to carry out their duties).
    8. we may identify you by name and location in any of our residential care facilities in accordance with federal, state, and local laws.
  1. As Required by Law for Public Health Activities
    Law also requires us to disclose health information about you for public health activities. These activities generally include prevention or control disease, injury, or disability; reporting deaths; reducing reactions to medications or problems with products; notifying people of recalls of products they may be using; and notifying a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition. Additionally, we may disclose proof of immunizations to a school where Pennsylvania or other similar law requires it prior to admitting a student.
  2. As Required by Law for Victims of Abuse or Neglect
    We may disclose your health information to a public health authority that is authorized by law to receive reports of child abuse or neglect. In addition, if we believe that you have been a victim of abuse, neglect, or domestic violence, we may disclose your health information to the governmental entity or agency authorized to receive such information. In this case, the disclosure will be made consistent with the requirements of applicable federal and state laws.
  3. For Research, Under Certain Circumstances
    Under certain circumstances, we may use of disclose your health information for research, subject to certain safeguards. For example, we may disclose information to researchers when their research has been approved by a special committee that has to review the research proposal and established protocols to ensure the privacy of your health information. We may disclose health information about you to people preparing to conduct a research project; however, the information will stay on site.
  4. Health Information Exchange
    MLS may share your health records electronically with the local Health Information Exchange (HIE) for the purposes of improving the overall quality of health care services provided to you (such as avoiding unnecessary duplicate testing). The HIE functions as our business associate and, in acting on our behalf, the HIE will transmit, maintain and store your health information for treatment, payment, and health care operation purposes. The HIE has a duty to implement administrative, physical and technical safeguards that reasonably and appropriately protect the confidentiality and integrity of your medical information.
  5. Other Uses & Disclosures
    Other Permitted and Required Uses and Disclosures will be made only with your consent, authorization or opportunity to object unless otherwise required by law. For example, we may disclose your health information for certain MLS fundraising activities. We may also use and disclose health information for certain health promotion activities. For example, your name and address may be used to send you a general newsletter or specific information based on your own health concerns.
    However, any fundraising or health promotion communication sent to you will let you know how you can exercise your right to opt-out of receiving similar communications in the future.

Uses & Disclosures Requiring Permission

Other uses and disclosures of health information not covered by this notice or the laws that apply to us will be made only with your written permission. For example, subject to certain limited exceptions, your written permission is required in any circumstance where MLS may receive direct or indirect payment in exchange for making the communication to you which encourages you to purchase a product or services or for a disclosure to a third party who wants to market products or services to you, your written permission is required for any sale of health information.

If you provide us permission to use or disclose health information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose health information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your permission and that we are required to retain our records of the care that we provided to you.

Your rights regarding health information about you

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

Right to Inspect and Copy

You have the right to inspect and copy health information that may be used to make decisions about your care. This usually includes health and billing records.

To inspect and copy health information that may be used to make decisions about you, you must submit your request in writing to the MLS Privacy Officer. 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. If you agree, we may provide you with a summary of the information instead of a copy of your entire record or with an explanation of the information instead of a copy. Before providing you with such a summary or explanation, we first will obtain your agreement to pay the fees, if any, for preparing the summary or explanation.

We may deny your request to inspect and copy your health information in certain very limited circumstances, such as when your physician determines that for health reasons this is not advisable. If you are denied access to health information, you may request that the denial be reviewed. Another licensed health care professional chosen by the organization will review your request and the denial. The person conducting the review will not be the person who denied your request. We will do what this person decides.

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 MLS.

To request an amendment, your request must be made in writing to Privacy Officer, Mainstay Life Services, 200 Roessler Road, Pittsburgh, PA 15220. You must provide a reason that supports your 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. We may also deny your request if you ask us to amend information that: (1) was not created by us, unless the person or entity that created it is no longer available to make the amendment; (2) is not part of the health information kept by or for MLS; (3) is not part of the information which you would be permitted to inspect or copy; or (4) 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 some of the disclosures we made of health information about you that were not specifically authorized by you in advance with the exception of the following disclosures:

  • For treatment, operations, and payment
  • To persons involved in your care
  • For national security or intelligence purposes, or
  • To correctional institutions or law enforcement officials

Your request must state a time period that must not be longer than six years and may not include dates before April 14, 2003. Your request should indicate in what form you want the list (for example: on paper, electronically). 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.

request must state a time period that may not be longer than six years and may not include dates before 14, 2003. Your request should indicate in what form you want the list (for example: on paper,

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. You also have the right to request a limitation on the health information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend. 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.

To request restrictions, you must make your request in writing. 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 Restrictions to a Health Plan

You have the right to request a restriction on disclosures of your health information to a health plan (for purposes of payment or healthcare operations) in cases where you have paid out of pocket, in full, for items received or services rendered by MLS.

Right to Confidential Communications

You have the right to request to receive communications from us by using alternative means for receipt of information or by receiving the information at alternative locations. We must accommodate your request, if it is reasonable. Contact the MLS Privacy Officer if you require such confidential communications.

Right to a Paper Copy of This Notice

You have the right to a paper copy of this notice even if you received a copy electronically. You may ask us to give you a copy of this notice at any time. To obtain a paper copy of this notice, request a copy from the Privacy Officer.

Breach of Unsecured Information

If a breach of unsecured health information affecting you occurs, MLS is required to notify you of the breach in writing and indicate any and all remedies and corrective actions taken to respond to the breach.

Changes to this Notice

We reserve the right to change this notice. 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. We will post a copy of the current notice in the organization. The notice will contain on the first page, in the top right- hand corner, the effective date.


If you believe your privacy rights have been violated, you may file a complaint with MLS or with the Secretary of the Department of Health and Human Services. To file a complaint with MLS, contact the MLS Compliance Officer. All complaints must be submitted in writing. You will not be penalized for filing a complaint.

Other Uses of Health Information

If you have any questions about this notice, please contact your program manager or the MLS Compliance Officer.