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.

American Republic Insurance Company
Notice of Privacy Practices
Effective April 14, 2003

At American Republic Insurance Company, we respect the confidentiality of your health information and will protect your information in a responsible and professional manner. We are required by law to maintain the privacy of your health information and to send you this notice.

This notice explains how we use information about you and when we can share that information with others. It also informs you of your rights with respect to your health information and how you can exercise those rights.

When we talk about "information" or "health information" in this notice we mean individually identifiable health information, as defined by the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

Individually identifiable health information is health information that:

• Is created or received by American Republic Insurance Company’s designated health care components;
• Relates to the past, present, or future physical or mental health condition of an individual, the provision of health care to an individual, or the past, present, or future payment for the provision of health care to an individual; and
• Identifies the individual, or with respect to which there is a reasonable basis to believe the information can be used to identify the individual.

How We Use or Share Information

Subject to state and federal laws, we are permitted to use and/or share your information without your authorization in certain circumstances, such as:

• To use or disclose the information for payment purposes. For example, we may use the information to help pay medical bills that have been submitted to us by doctors and hospitals for payment or to contact your doctor to obtain medical records in order to make claim payment decisions.
• To use or disclose the information to perform health care operations. For example, we may use the information for activities relating to underwriting; customer service; legal services; and auditing functions, including fraud and abuse detection and compliance programs.
• To use or disclose your information to provide you with information about health related benefits and services that you may be interested in.
• If you are available and do not object, we may disclose information to a member of your family, a friend, or other person you identify who is involved in your health care or the payment of a claim. If you are unavailable, incapacitated, or facing an emergency medical situation, and we determine that a limited disclosure is in your best interest, we may share limited information with such persons.
• To disclose information to a disaster relief organization in order for the organization to communicate with a family member or other person involved in your care.

There are also state and federal laws that may require or permit us to release your information to others without your authorization.

• To use and disclose information to the extent required to comply with the law.
• To report information to state and federal agencies that regulate us such as the U.S. Department of Health and Human Services and the Iowa Division of Insurance.
• To share information for public health activities. For example, we may report information to government authorities conducting public health investigations.
• To use or disclose information to avert a serious health or safety threat.
• To share information with a health oversight agency for certain oversight activities authorized by law. For example audits, inspections, licensure, and disciplinary actions.
• To disclose information in the course of a judicial or administrative proceeding. For example pursuant to a valid court order or subpoena.
• To report information for law enforcement purposes. For example, we may give information to a law enforcement official for purposes of identifying or locating a suspect, fugitive, material witness or missing person.
• To report information to a government authority regarding child abuse, neglect or domestic violence.
• To share information with a coroner or medical examiner to identify a deceased person, determine a cause of death, or as authorized by law. We may also share information to a funeral director as necessary to carry out their duties.
• To use or share information for procurement, banking or transplantation of organs, eyes, or tissue.
• To use or disclose information for research purposes, but only as permitted by law.
• To share information for specialized government functions, such as military and veteran activities, national security and intelligence activities, and the protective services for the President and others.
• To report information on job-related injuries because of requirements of your state workers’ compensation laws.

In the event that an applicable law prohibits or materially limits one of the uses or disclosures of information described above, we will estrict the use or disclosure in accordance with the more stringent law.

If one of the above reasons for a use or disclosure does not apply, we must get your written permission, in the form of an authorization, to use or disclose your information. If you give us written permission and change your mind you may revoke your authorization at any time except to the extent that we have taken action in reliance on the authorization or, if the authorization was obtained as a condition of obtaining insurance coverage, other law provides us with the right to contest a claim under the policy or the policy itself.

What Are Your Rights

The following are your rights with respect to your information. If you would like to exercise the following rights, please contact our Customer Service Center. Contact information for our Customer Service Center is located at the end of this Notice.

• You have the right to ask us to restrict how we use or disclose your information for payment or health care operations. You also have the right to ask us to restrict information that we have been asked to give to family members or to others who are involved in your health care or payment for your health care and uses and disclosures for disaster relief purposes. Please note that while we will try to accommodate reasonable requests, we are not required to agree to these restrictions.
• You have the right to request confidential communications of information. For example, if you believe that you would be harmed if we send your information to your current mailing address (for example, in situations involving domestic disputes or violence), you can ask us to send the information by alternative means (for example, by fax) or to an alternative address. We will accommodate your reasonable requests as explained above.
• You have the right to copy and inspect certain components of your information that we maintain. All requests for access must be made in writing and signed by you or your representative. Access request forms are available from our Customer Service Center at the address below. We may charge you a fee for copying and postage.
• You have the right to request that certain components of your information be amended to correct an error or omission. We are not obligated to make all requested amendments but will give each request careful consideration. All amendment requests must be in writing, signed by you or your representative, and must state the reasons for the requested amendment. Amendment request forms are available from our Customer Service Center at the address below.
• You have the right to receive an accounting of certain disclosures of your information. Please note that we are not required to provide you with an accounting of the following information:
• Any information collected prior to April 14, 2003.
• Information disclosed or used for treatment, payment, and/or health care operations purposes.
• Information disclosed to you or pursuant to your authorization.
• Information that is incidental to a use or disclosure otherwise permitted.
• Information disclosed for a facility’s directory or to person involved in your care or other notification purposes.
• Information disclosed for national security or intelligence purposes.
• Information disclosed to correctional institutions, law enforcement officials or health oversight agencies.
• Information that was disclosed or used as part of a limited data set for research, public health, or health care operations purposes.

Accounting requests forms are available from our Customer Service Center at the address below. The first accounting in any 12-month period is free; however, we may charge you a fee for each subsequent accounting you request in the same 12-month period.

Exercising Your Rights

• You have a right to receive a copy of this notice upon request at any time. You can also view a copy of this notice on our website at www.americanrepublic.com. We are required to abide by the terms of this notice. Should any of our privacy practices change, we reserve the right to change the terms of this notice and to make the new notice effective for all protected health information we maintain. Once revised, we will provide the new notice to you by mail and post it on our website.
  
  If you believe your privacy rights have been violated, you may file a complaint with us by contacting our Customer Service Center. You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services. We will not take any action against you for filing a complaint.

Contact Information

If you have any questions or complaints, please contact:

American Republic Insurance Company Customer Service Center P.O. Box 9371 Des Moines, Iowa 50306 -9371 1-800-247-2190 Monday through Friday 6:30 a.m. to 6:00 p.m., Central Time www.americanrepublic.com

01 115 3299 0303 US