The Privacy Rule included as part of the Health Insurance Portability and Accountability Act (HIPAA), provides federal protections for individually identifiable health information and gives patients an array of rights with respect to that information. Privacy and confidentiality of our customers health information are long standing principals in the way we, at Medical Mutual of Ohio, conduct business. We strive to give our customers peace of mind that their health information is protected and remains confidential within guidelines established by law and sound business practice.

HIPAA protects health information relating to past, present or future physical or mental health of an individual. Any health information that can be directly linked or associated with an individual is referred to as “protected health information” or PHI for short. Protected health information can be in written, electronic or oral form. For more information please visit U. S. Department of Health & Human Services under the heading of Health Information Privacy.

The following is important information about how we at Medical Mutual protect your health information and your rights with regard to your information. 

Notice of Privacy Practices
Notice describing how Medical Mutual of Ohio uses and discloses PHI, your rights under HIPAA and how you can exercise those rights.

Request to Access Protected Health Information
Your right to review records contained in Medical Mutual of Ohio’s designated record set.

Request for an Amendment of Protected Health Information
Your right to request changes to be made to correct errors in your records or add information that has been omitted.

Request for an Accounting of Disclosures
Your right to see a list of certain disclosures made of your protected health information.

Request for a Restriction on the Use or Disclosure of Protected Health Information
Your right to request special treatment of your protected health information.

Request Confidential Communications
Your right to receive information from Medical Mutual of Ohio at an alternate address.

Request to Revoke Confidential Communications
Your right to cancel your request to receive information from Medical Mutual of Ohio at an alternate address.

Request an Authorized Contact
Your right to designate a person that is legally permitted to act on your behalf (e.g. Power of Attorney, legal guardian).

Request to Revoke Authorized Contact
Your right to cancel your authorized contact.

Release of Protected Health Information Authorization Form
Your right to designate anyone to receive your information.  (Note:  The designee does not have to be a legal authority).

Revocation of Protected Health Information Authorization Form
Your right to cancel your request for Authorization for the use or disclosure of your protected health information.

Complain About a Violation of Confidentiality or Privacy Rights
Your right to complain to Medical Mutual of Ohio or to the United States Department of Health and Human Services.

Privacy & Confidentiality

IMPORTANT NOTICE TO ALL INSUREDS 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.

Download a printable PDF version of the Notice of Privacy Practices.

View our website Privacy Policy.

Request to Access Protected Health Information

You have the right to review your records contained in Medical Mutual of Ohio’s Designated Record Set (DRS). A DRS is a summary of all your protected health information that Medical Mutual of Ohio has about your eligibility, claims, customer care, care management and prescription information. If you would like to access your entire medical record, you will need to contact the provider of the service.

The steps to request Access are:

  1. Obtain a Request to Access Protected Health Information Form by clicking on this link or by calling our Customer Care Center for this form at the telephone number on your identification card.
  2. Complete this form including all pertinent information. Please note that Medical Mutual of Ohio will not be able to process an incomplete form and you will NOT BE NOTIFIED if this situation arises.
  3. Keep in mind as you are completing the form that if you are requesting records from a phone call to our Customer Care Center, you must include the date and time you called Medical Mutual of Ohio. If you are requesting claims information, you must include the claim number, date of service and provider.
  4. Sign the completed form and send to:
    Medical Mutual of Ohio P.O. Box 89499 Cleveland, Ohio 44101-6499
    Please note: If you obtained your form at our website, please print it out when completed. All requests must have a signature and be sent to the address above. Requests will not be accepted if sent via email.
  5. When your request is received, the necessary steps will be taken by the Medical Mutual of Ohio Staff to send you the information in a reasonable time frame.
    Please note: You may send your request in writing instead of using the Privacy & Confidentiality Form, but the request must include: your name, your birthday, the policy number under which you are covered, the group number under which you are covered, your social security number, the information you would like to access and the dates of information you would like to see (if applicable). Again, please note that Medical Mutual of Ohio will not be able to process a request that does not include all the necessary information and you will NOT BE NOTIFIED if this situation arises.

Request for an Amendment of Protected Health Information

You have the right to request changes be made to correct errors in your records or add information that has been omitted. There are distinct limitations to what information that can be changed, by whom and under what circumstances. Medical Mutual of Ohio cannot amend information it did not create and will refer you to the provider of service if you are requesting an amendment to diagnosis or treatment information. Please note that Medical Mutual of Ohio has the right to deny the request to amend your information, but you can appeal the denial. These rights would be explained to you if you choose to appeal the denial.

The steps to requests to Amend information are:

  1. Obtain a Request for an Amendment of Protected Health Information by clicking on this link or by calling our Customer Care Center for this form at the telephone number on your identification card.
  2. Complete this form including all pertinent information. Please note that Medical Mutual of Ohio will not be able to process an incomplete form and you will NOT BE NOTIFIED if this situation arises.
  3. If possible please attach a copy of the document to be amended.
  4. Sign the completed form and send to:
    Medical Mutual of Ohio P.O. Box 89499 Cleveland, Ohio 44101-6499
    Please note: If you obtained your form at our website, please print it out when completed. All requests must have a signature and be sent to the address above. Requests will not be accepted if sent via email.
  5. When your request is received, the necessary steps will be taken by the Medical Mutual of Ohio Staff to send you the information in a reasonable time frame.
    Please note: You may send your request in writing instead of using the Privacy & Confidentiality Form, but the request must include: your name, your birthday, the policy number under which you are covered, the group number under which you are covered, your social security number, the information you would like to access and the dates of information you would like to see (if applicable). Again, please note that Medical Mutual of Ohio will not be able to process a request that does not include all the necessary information and you will NOT BE NOTIFIED if this situation arises.

Request for an Accounting of Disclosures

You have the right to an accounting of certain disclosures of your information made by Medical Mutual of Ohio and its Business Associates over the last six (6) years.

The steps to request an accounting of your disclosures:

  1. Obtain a Request for an Accounting of Disclosures Form by clicking on this link or by calling our Customer Care Center for this form at the telephone number on your identification card.
  2. Complete this form including all pertinent information. Please note that Medical Mutual of Ohio will not be able to process an incomplete form and you will NOT BE NOTIFIED if this situation arises.
  3. Sign the completed form and send to:
    Medical Mutual of Ohio P.O. Box 89499 Cleveland, Ohio 44101-6499
    Please note: If you obtained your form at our website, please print it out when completed. All requests must have a signature and be sent to the address above. Requests will not be accepted if sent via email.
  4. When your request is received, the necessary steps will be taken by the Medical Mutual of Ohio Staff to send you the information in a reasonable time frame.
    Please note: You may send your request in writing instead of using the Privacy & Confidentiality Form, but the request must include: your name, your birthday, the policy number under which you are covered, the group number under which you are covered, your social security number, the information you would like to access and the dates of information you would like to see (if applicable). Again, please note that Medical Mutual of Ohio will not be able to process a request that does not include all the necessary information and you will NOT BE NOTIFIED if this situation arises.

Request for a Restriction on the Use or Disclosure of Protected Health Information

You have the right to request that your information receive special treatment, meaning that you can request additional restrictions on your information when used for treatment, payment, or other day-to-day operations. Please note that Medical Mutual of Ohio is not required to agree to the restriction.

The steps to request restriction:

  1. Obtain a Request for a Restriction on the Use or Disclosure of Protected Health Information Form by clicking on this link or by calling our Customer Care Center for this form at the telephone number on your identification card.
  2. Complete this form including all pertinent information. Please note that Medical Mutual of Ohio will not be able to process an incomplete form and you will NOT BE NOTIFIED if this situation arises.
  3. Sign the completed form and send to:
    Medical Mutual of Ohio P.O. Box 89499 Cleveland, Ohio 44101-6499
    Please note: If you obtained your form at our website, please print it out when completed. All requests must have a signature and be sent to the address above. Requests will not be accepted if sent via email.
  4. When your request is received, the necessary steps will be taken by the Medical Mutual of Ohio Staff to send you the information in a reasonable time frame.
    Please note: You may send your request in writing instead of using the Privacy & Confidentiality Form, but the request must include: your name, your birthday, the policy number under which you are covered, the group number under which you are covered, your social security number, the information you would like to access and the dates of information you would like to see (if applicable). Again, please note that Medical Mutual of Ohio will not be able to process a request that does not include all the necessary information and you will NOT BE NOTIFIED if this situation arises.

Request Confidential Communications

You have the right to request to receive communications of your protected health information at an alternate location. Please note that Medical Mutual of Ohio does not have to honor this request unless:

Your request will take ten (10) business days to process from the date received. All communications regarding your information will be sent to the alternate address once you receive the confirmation letter (sent to the alternate address) or until you notify us otherwise. Please note that the use of an alternate address cannot be applied to communications sent prior to processing your request.

The steps to request confidential communication:

  1. Obtain a Confidential Communications Request Form by clicking on this link or by calling our Customer Care Center for this form at the telephone number on your identification card.
  2. Complete this form including all pertinent information. Please note that Medical Mutual of Ohio will not be able to process an incomplete form and you will NOT BE NOTIFIED if this situation arises.
  3. Sign the completed form and send to:
    Medical Mutual of Ohio P.O. Box 89499 Cleveland, Ohio 44101-6499
    Please note: If you obtained your form at our website, please print it out when completed. All requests must have a signature and be sent to the address above. Requests will not be accepted if sent via email.
  4. When your request is received, the necessary steps will be taken by the Medical Mutual of Ohio Staff to send you the information in a reasonable time frame.
    Please note: You may send your request in writing instead of using the Privacy & Confidentiality Form, but the request must include: your name, your birthday, the policy number under which you are covered, the group number under which you are covered, your social security number, the information you would like to access and the dates of information you would like to see (if applicable). Again, please note that Medical Mutual of Ohio will not be able to process a request that does not include all the necessary information and you will NOT BE NOTIFIED if this situation arises.

Request to Revoke Confidential Communications

You have the right to revoke the alternate address that you are currently having protected health information sent to.

The steps to revoke confidential communications:

  1. Obtain a Revocation of Confidential Communications Form by clicking on this link or by calling our Customer Care Center for this form at the telephone number on your identification card.
  2. Complete this form including all pertinent information. Please note that Medical Mutual of Ohio will not be able to process an incomplete form and you will NOT BE NOTIFIED if this situation arises.
  3. Sign the completed form and send to:
    Medical Mutual of Ohio P.O. Box 89499 Cleveland, Ohio 44101-6499
    Please note: If you obtained your form at our website, please print it out when completed. All requests must have a signature and be sent to the address above. Requests will not be accepted if sent via email.
  4. When your request is received, the necessary steps will be taken by the Medical Mutual of Ohio Staff to send you the information in a reasonable time frame.
    Please note: You may send your request in writing instead of using the Privacy & Confidentiality Form, but the request must include: your name, your birthday, the policy number under which you are covered, the group number under which you are covered, your social security number, the information you would like to access and the dates of information you would like to see (if applicable). Again, please note that Medical Mutual of Ohio will not be able to process a request that does not include all the necessary information and you will NOT BE NOTIFIED if this situation arises.

Request an Authorized Contact

You have the right to request to have a legally permitted person (e.g Power of Attorney, legal guardian) to act on your behalf when resolving claims or customer care issue or when seeking benefit information from your plan. This authorized contact may act on your behalf until you notify Medical Mutual of Ohio to revoke the request.

The steps to authorize a contact to act on your behalf:

  1. Obtain an Authorized Contact Request Form by clicking on this link or by calling our Customer Care Center for this form at the telephone number on your identification card.
  2. Complete this form including all pertinent information. Please note that Medical Mutual of Ohio will not be able to process an incomplete form and you will NOT BE NOTIFIED if this situation arises.
  3. Sign the completed form and send to:
    Medical Mutual of Ohio P.O. Box 89499 Cleveland, Ohio 44101-6499
    Please note: If you obtained your form at our website, please print it out when completed. All requests must have a signature and be sent to the address above. Requests will not be accepted if sent via email.
  4. When your request is received, the necessary steps will be taken by the Medical Mutual of Ohio Staff to send you the information in a reasonable time frame.
    Please note: You may send your request in writing instead of using the Privacy & Confidentiality Form, but the request must include: your name, your birthday, the policy number under which you are covered, the group number under which you are covered, your social security number, the information you would like to access and the dates of information you would like to see (if applicable). Again, please note that Medical Mutual of Ohio will not be able to process a request that does not include all the necessary information and you will NOT BE NOTIFIED if this situation arises.

Request to Revoke Authorized Contact

You have the right to revoke the legally permitted person (e.g. Power of Attorney, legal guardian) who is acting on your behalf when resolving claims or customer care issue or when seeking benefit information from your plan.

The steps to revoke and authorized contact:

  1. Obtain a Revocation of Authorized Contact by clicking on this link or by calling our Customer Care Center for this form at the telephone number on your identification card.
  2. Complete this form including all pertinent information. Please note that Medical Mutual of Ohio will not be able to process an incomplete form and you will NOT BE NOTIFIED if this situation arises.
  3. Sign the completed form and send to:
    Medical Mutual of Ohio P.O. Box 89499 Cleveland, Ohio 44101-6499
    Please note: If you obtained your form at our website, please print it out when completed. All requests must have a signature and be sent to the address above. Requests will not be accepted if sent via email.
  4. When your request is received, the necessary steps will be taken by the Medical Mutual of Ohio Staff to send you the information in a reasonable time frame.
    Please note: You may send your request in writing instead of using the Privacy & Confidentiality Form, but the request must include: your name, your birthday, the policy number under which you are covered, the group number under which you are covered, your social security number, the information you would like to access and the dates of information you would like to see (if applicable). Again, please note that Medical Mutual of Ohio will not be able to process a request that does not include all the necessary information and you will NOT BE NOTIFIED if this situation arises.

Release of Protected Health Information Authorization Form

You have the right to request to request a person to receive your protected health information.  This authorized contact may receive your protected health information until you notify Medical Mutual of Ohio to revoke this request.

  1. Obtain a Release of Protected Health Information Authorization Form by clicking on this link or by calling our Customer Care Center for this form at the telephone number on your identification card.
  2. Complete this form including all pertinent information. Please note that Medical Mutual of Ohio will not be able to process an incomplete form and you will NOT BE NOTIFIED if this situation arises.
  3. Sign the completed form and send to:
    Medical Mutual of Ohio P.O. Box 89499 Cleveland, Ohio 44101-6499
    Please note: If you obtained your form at our website, please print it out when completed. All requests must have a signature and be sent to the address above. Requests will not be accepted if sent via email.
  4. When your request is received, the necessary steps will be taken by the Medical Mutual of Ohio Staff to send you the information in a reasonable time frame.
    Please note: You may send your request in writing instead of using the Privacy & Confidentiality Form, but the request must include: your name, your birthday, the policy number under which you are covered, the group number under which you are covered, your social security number, the information you would like to access and the dates of information you would like to see (if applicable). Again, please note that Medical Mutual of Ohio will not be able to process a request that does not include all the necessary information and you will NOT BE NOTIFIED if this situation arises.

Revocation of Protected Health Information Authorization Form

You have the right to revoke the person receiving your protected health information.   

The steps to revoke requested authorization for the Use or Disclosure of Protected Health Information:

  1. Obtain a Revocation of Protected Health Information Authorization Form by clicking on this link or by calling our Customer Care Center for this form at the telephone number on your identification card.
  2. Complete this form including all pertinent information. Please note that Medical Mutual of Ohio will not be able to process an incomplete form and you will NOT BE NOTIFIED if this situation arises.
  3. Sign the completed form and send to:
    Medical Mutual of Ohio P.O. Box 89499 Cleveland, Ohio 44101-6499
    Please note: If you obtained your form at our website, please print it out when completed. All requests must have a signature and be sent to the address above. Requests will not be accepted if sent via email.
  4. When your request is received, the necessary steps will be taken by the Medical Mutual of Ohio Staff to send you the information in a reasonable time frame.
    Please note: You may send your request in writing instead of using the Privacy & Confidentiality Form, but the request must include: your name, your birthday, the policy number under which you are covered, the group number under which you are covered, your social security number, the information you would like to access and the dates of information you would like to see (if applicable). Again, please note that Medical Mutual of Ohio will not be able to process a request that does not include all the necessary information and you will NOT BE NOTIFIED if this situation arises.

Complain About a Violation of Confidentiality or Privacy Rights

You have the right to complain if you believe your privacy rights have been violated. You also have the right to complain, in writing, to the Secretary of the United States Department of Health and Human Services at the Hubert Humphrey building, 200 Independence Avenue, S.W., Washington, D.C. 20201. Please note the federal law prohibits retaliation against you if you chose to file a complaint.

The steps to complain about a violation of your Privacy Rights:

  1. Obtain a Violation of Confidentiality or Privacy Form by clicking on this link or by calling our Customer Care Center for this form at the telephone number on your identification card.
  2. Complete this form including all pertinent information. Please note that Medical Mutual of Ohio will not be able to process an incomplete form and you will NOT BE NOTIFIED if this situation arises.
  3. Sign the completed form and send to:
    Medical Mutual of Ohio P.O. Box 89499 Cleveland, Ohio 44101-6499
    Please note: If you obtained your form at our website, please print it out when completed. All requests must have a signature and be sent to the address above. Requests will not be accepted if sent via email.
  4. When your request is received, the necessary steps will be taken by the Medical Mutual of Ohio Staff to send you the information in a reasonable time frame.
    Please note: You may send your request in writing instead of using the Privacy & Confidentiality Form, but the request must include: your name, your birthday, the policy number under which you are covered, the group number under which you are covered, your social security number, the information you would like to access and the dates of information you would like to see (if applicable). Again, please note that Medical Mutual of Ohio will not be able to process a request that does not include all the necessary information and you will NOT BE NOTIFIED if this situation arises.