This notice describes how personal health information about you may be used and disclosed and how you can get access to this information.

Annual Notification
First Source Benefits Group Privacy Policy

Legislation requires that we provide all existing customers with this privacy notice once each year. In accordance with that law, we want to share with you our policy regarding nonpublic personal information we receive about individuals who are our current customers or potential customers.

Nonpublic Personal Information We May Collect About Individuals
We may collect personal financial information from you such as net worth, annual income, and marginal income tax bracket. We may also collect personal health information such as medical history. We only disclose personal health information with your prior written authorization or as otherwise permitted or required by law. In the remainder of this notice, references to nonpublic personal information exclude all personal health information.

We collect nonpublic personal information from the following sources:

  • Information we receive from you on applications or other forms such as your name, address, social security number, assets and income.
  • Information about your transactions with third parties such as annuity companies for which we serve as your representative or agent of record.
  • Information we receive or obtain during your visits to our website.

Categories of Parties to Whom We May Disclose Information
We may disclose nonpublic information that we collect about you to the following types of third parties:

  • Financial service providers such as life insurance and annuity companies.
  • Third parties that support our services, such as printing companies and technology system vendors.
  • Third parties that conduct audit services for our operations.
  • Law enforcement and regulatory agencies as required by law.
  • Employers, plan sponsors, third party administrators or any other association with regard to any group product serviced by us.

We will only disclose information in limited circumstances as permitted by law. We maintain physical, electronic and procedural safeguards that comply with applicable law to guard your nonpublic personal information.

We do not sell any of your information under any circumstance.

Opt Out Right
If you prefer that we not disclose nonpublic personal information about you to nonaffiliated third parties, you may opt out of those disclosures (other than those disclosures permitted by law). To exercise your right to opt out of disclosure of your nonpublic personal information, please notify us in writing at: First Source Benefits Group, LLC, 7908 Cincinnati-Dayton Road, Suite I, West Chester, Ohio 45069.

If you have any questions about our privacy policy, please contact us at:
First Source Benefits Group, LLC
7908 Cincinnati-Dayton Road, Suite I
West Chester, Ohio 45069
Tel 513.759.7644
Fax 513.759.7645

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Notice of Privacy Practices

This notice describes how personal health information about you may be used and disclosed and how you can get access to this information.

PLEASE READ CAREFULLY

Questions
If you have any questions about this notice, please contact:
William Brunk
First Source Benefits Group, LLC
7908 Cincinnati-Dayton Road, Suite I
West Chester, Ohio 45069
Tel 513.759.7644
Fax 513.759.7645

We understand that health information about you is personal. We are committed to protecting the personal health information that we maintain as part of the group health care coverage that we sponsor. We have set up policies and procedures to make sure that this health coverage information that identifies you is kept private.

This notice applies to all personal health information that First Source Benefits Group, LLC maintains. It will tell you about the ways that we may use and share personal health information about you. It describes our responsibilities for personal health information that we use. Also, this notice tells you about your rights in relation to your personal health information.

First Source Benefits Group’s Obligation Regarding Personal Health Information
First Source Benefits Group, LLC [hereafter "FSBG"] are required by law to make sure that we protect and safeguard your personal health information that we maintain.

  • We must give you this notice that describes our legal duties and our privacy practices concerning your personal health information.
  • We must take reasonable efforts to release only the minimum personal health information necessary to accomplish the use, disclosure or request.
  • By law, we must follow the terms of our privacy notice that is currently in effect.

Use and Disclosure of Personal Health Information
This notice describes the personal health information practices of FSBG in its role of employer sponsor of group health coverage for you. It also describes the responsibilities and obligations that FSBG has placed on a third party or insurance carrier that provides or assists in the administration of the health care coverage that you have through FSBG.

To provide you with group health care coverage, it is necessary for FSBG to plan to collect, store, use and share with others, personal health information about those who have our health care coverage.

Categories of Personal Health Information that We Use
First Source Benefits Group, LLC [hereafter "FSBG"] are required by law to make sure that we protect and safeguard your personal health information that we maintain.

To Obtain and Manage Health Care Coverage the collection, use and sharing of personal health information is necessary to get health coverage for our employees and eligible dependents. For instance, we may use personal health information to: get premium quotes from insurance carriers or third party administrators or obtain premium underwriting; submit claims for stop-loss or excess loss coverage; obtain legal, accounting, and audit services; manage costs, conduct business management and administrative activities related to the health care coverage.

To Help With Treatment FSBG itself does not directly provide any health care treatment. However, we may use or share your personal health care information to help health care providers serve or treat you. For example, we may share information about allergies to a hospital emergency department if needed to render appropriate emergency care.

To Obtain Payment of Claims FSBG may use or share your personal health information to make payment possible for covered health care that you receive. This includes determining eligibility for coverage benefits and coordinating coverage with other health care plans. For instance, FSBG may tell a health care provider about your medical history to help decide if particular treatment is covered under our group health plan. Also, we may share personal health information with another carrier or third party payor to determine payment responsibility. FSBG may also disclose health information related to a worker’s compensation program or a work-related illness or injury.

To Comply with Laws and Government Authorities FSBG will disclose your personal health information when required by federal, state or local law, regulation, or court or government agency order. For example, as permitted or required by law, we must reveal personal health information when: required to work with public officials to prevent or manage a serious threat to public health or safety; required for government monitoring of health care, civil rights laws, or other government oversight activities; ordered to do so by a court or other lawful process relating to a civil lawsuit or criminal matter; and directed by law enforcement officials, coroners, medical examiners, or national security officials in the lawful pursuit of their duties. If ordered by a court or other legal process to provide personal health information about you, FSBG will make an effort to tell you about the request.

Your Rights Regarding Your Personal Health Information
You, or a personal representative that you designate, have the following rights regarding any of your personal health information that we may maintain.

Right to Authorize Other Uses and Disclosures
Other uses or disclosures of your personal health information not covered by this notice will be made only with your written and signed permission or authorization.

If you give written permission or authorization to disclose your personal health information, you may revoke the authorization or remove the permission at any time. To revoke the authorization or remove the permission, you must tell us in writing. If we have released information before receiving your request to revoke the authorization or remove permission, we will not be able to take that information back.

Right to Request Restriction on Certain Uses/Disclosures
You have the right to ask for a limitation or restriction on the personal health care information that we use and maintain for treatment, payment or health care operations. You also have the right to request a restriction or limitation on the information that we disclose to someone involved in your care or payment for your care. For example, you could ask that we not disclose a surgery that you had to a family member or a friend. The law says that we are not required to agree to your request.

To ask for a restriction or limitation, send a written request to:
William Brunk
First Source Benefits Group, LLC
7908 Cincinnati-Dayton Road, Suite I
West Chester, Ohio 45069

In your written request, you must tell us:

  • What information you want us to limit;
  • Do you want us to limit our use, disclosure or both use and disclosure;
  • To whom you want the limits to apply, for example, your spouse.

Right to Receive Confidential Communications
You have the right to ask that we communicate with you about personal health care matters in a certain way. For instance, we can ask that we only contact you about personal health care matter at work, or only by mail.

To ask for confidential communications, you must send a written request to:
William Brunk
First Source Benefits Group, LLC
7908 Cincinnati-Dayton Road, Suite I
West Chester, Ohio 45069

Do not tell us the reason for your request. You must tell us in the request how or where you wish to receive a communications that has personal health information. We will comply with any reasonable request.

Right to Inspect and Copy Personal Health Information
You have the right to inspect and copy any of your personal health information that FSBG maintains in relation to our group health coverage that is used for making health care decisions or claims payment. If you request a copy of this personal health information, we can 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 in certain very limited circumstances, as permitted by law. If we deny access to your personal health information, you may request that the denial be reviewed.

To ask for an inspection or copy of your personal health information, you must send a written request to:
William Brunk
First Source Benefits Group, LLC
7908 Cincinnati-Dayton Road, Suite I
West Chester, Ohio 45069

Right to Amend Personal Health Information
You have the right to ask FSBG to amend or change your personal health information that we have if you believe that the information is incomplete or inaccurate.

To ask for a change in your personal health information that we have, you must send a written request to:
William Brunk
First Source Benefits Group, LLC
7908 Cincinnati-Dayton Road, Suite I
West Chester, Ohio 45069

We may deny your request for any of the following reasons:

  • It is not in writing or it does not contain a reason to support why you think that the information is incomplete or inaccurate;
  • The information is not kept by FSBG;
  • The information was not created by FSBG, unless the person or entity that created the information is no longer available to make the change;
  • The information is not part of the personal health information that you have a right to inspect or copy;
  • The information is accurate and complete.

Right to Receive Accounting of Disclosures
You have the right to receive a list or accounting of any non-incidental disclosures of the personal health information we have about you that are not authorized by you, not permitted by law or regulation, or related to treatment, payment or group health plan operations. When we become aware of any disclosures not authorized by you or permitted by law or regulation, we will inform you in writing.

Right to a Paper Copy of this Notice
You have the right to another paper copy of this notice. You may ask FSBG for it at any time. To get a paper copy of this notice, contact:
William Brunk
First Source Benefits Group, LLC
7908 Cincinnati-Dayton Road, Suite I
West Chester, Ohio 45069
Tel 513.759.7644

Changes to this Notice
FSBG reserves the right to change this notice and to make new notice provisions effective for all personal health information that it maintains or collects in the future. If we change this notice, we will send you a copy of the changed notice.

Complaints
If you believe that your privacy rights have been violated in relation to personal health information that FSBG maintains or uses, you may file a complaint with FSBG or with the Secretary of the Department of Health and Human Services. All complaints must be submitted in writing.

You will not be penalized for filing a complaint.

To file a complaint with FSBG, contact:
William Brunk
First Source Benefits Group, LLC
7908 Cincinnati-Dayton Road, Suite I
West Chester, Ohio 45069
Tel 513.759.7644

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