TO ALL PARTICIPANTS AND ADULT FAMILY MEMBERS OR PARTICIPANTS COVERED BY THE LOCAL 734 WELFARE FUND
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED BY THE LOCAL 734 WELFARE FUND (HEREINAFTER “THE FUND”) AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
USE AND DISCLOSURE OF HEALTH INFORMATION
The Fund may use your health information, that is, information that constitutes protected health information as defined in the Privacy Rule of the Administrative Simplification provision of the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), for purposes of making or obtaining payment for your care and conducting health care operations. The Fund has established a policy to guard against unnecessary disclosure of your health information.
The Fund may use or disclose protected health information for certain purposes. Protected health information generally includes all individually identifiable health information transmitted or maintained by the Fund regardless of the form of this information, including oral, written and electronic information. Protected health information does not include “de-identified” information, which is information that does not identify an individual and with respect to which there is no reasonable basis to believe that the information can be used to identify an individual.
THE FOLLOWING IS A SUMMARY OF THE CIRCUMSTANCES UNDER WHICH AND PURPOSES FOR WHICH YOUR HEALTH INFORMATION MAY BE USED AND DISCLOSED:
TO MAKE OR OBTAIN PAYMENT – The Fund may use or disclose your protected health information for the purpose of “payment.” “Payment” includes but is not limited to actions regarding coverage determinations and payment, including billing, claims management and determination, subrogation, plan reimbursement, reviews for medical necessity and appropriateness of care, utilization review and preauthorization.
For example, the Fund may provide information regarding your coverage or health care treatment to another health plan under which you are covered to coordinate payment of benefits.
TO CONDUCT TREATMENT, PAYMENT OR HEALTH CARE OPERATIONS – The Fund may use or disclose health information for its own operations to facilitate the administration of the Fund and as necessary to provide coverage and services to all of the Fund’s participants. “Health care operations” includes such activities as:
For example, the Fund may use your health information to conduct case management or utilization review, to engage in customer service and appeal resolution activities, or to audit the accuracy of its claims processing function.
FOR TREATMENT ALTERNATIVES – The Fund may use and disclose your health information to tell you about or recommend possible treatment options or alternatives that may be of interest to you.
FOR DISTRIBUTION OF HEALTH-RELATED BENEFITS AND SERVICES – The Fund may use or disclose your health information to provide to you information on health-related benefits and services that may be of interest to you.
FOR DISCLOSURE TO THE PLAN SPONSOR – The Plan sponsor is the Board of Trustees of the Fund. The Fund may disclose your protected health information to the plan sponsor for the purposes of its administration of the Plan and for other functions specifically authorized under the Department of Health and Human Service Regulations Regarding Privacy of Individually Identifiable Health Information. This disclosure may be for purposes of the Fund’s treatment, payment and health care operations.
FOR DISCLOSURE TO A FAMILY MEMBER, RELATIVE, OR OTHER RESPONSIBLE PERSON
WHEN LEGALLY REQUIRED – The Fund will disclose your health information when it is required to do so by any federal, state or local law.
TO CONDUCT HEALTH OVERSIGHT ACTIVITIES – The Fund may disclose your health information to a health oversight agency for authorized activities including audits, civil administrative or criminal investigations, inspections, licensure or disciplinary action. The Fund, however, may not disclose your health information if you are the subject of an investigation and the investigation does not arise out of or is not directly related to your receipt of health care or public benefits.
IN CONNECTION WITH JUDICIAL AND ADMINISTRATIVE PROCEEDINGS – As permitted or required by state law, the Fund may disclose your health information in the course of any judicial or administrative proceeding in response to an order of a court or administrative tribunal as expressly authorized by such order or in response to a subpoena, discovery request or other lawful process, but only when the Fund makes reasonable efforts to either notify you about the request or to obtain an order protecting your health information.
FOR LAW ENFORCEMENT PURPOSES – As permitted or required by state law, the Fund may disclose your health information to a law enforcement official for certain law enforcement purposes, including, but not limited to, if the Fund has a suspicion that your death was the result of criminal conduct or in an emergency to report a crime.
IN THE EVENT OF A SERIOUS THREAT TO HEALTH OR SAFETY – The Fund may, consistent with applicable law and ethical standards of conduct, disclose your health information if the Fund, in good faith, believes that such disclosure is necessary to prevent or lessen a serious and imminent threat to your health or safety or to the health and safety of the public.
USE OR DISCLOSURE REGARDING VICTIMS OF ABUSE, NEGLECT OR DOMESTIC VIOLENCE – The Fund may use or disclose protected health information when authorized by law to report information about abuse, neglect or domestic violence to public authorities if there exists a reasonable belief that you may be a victim of abuse, neglect or domestic violence. In such case, the Fund will promptly inform you that such a disclosure has been or will be made unless that notice would cause a risk of serious harm. For the purpose of reporting child abuse or neglect, it is not necessary to inform the minor that such a disclosure has been or will be made. Disclosure may generally be made to the minor’s parents or other representatives although there may be circumstances under federal or state law when the parents or other representatives may not be given access to the minor’s private health information.
FOR SPECIFIED GOVERNMENT FUNCTIONS – In certain circumstances, federal regulations require the Fund to use or disclose your health information to facilitate specified government functions related to the military and veterans, national security and intelligence activities, protective services for the president and others, and correctional institutions and inmates.
DISCLOSURE CONCERNING PERSONS WHO HAVE DIED – The Fund may use or disclose protected health information when required to be given to a coroner or medical examiner for the purposes of identifying a deceased person, determining a cause of death or other duties as authorized by law. Also, disclosure is permitted to funeral directors, consistent with applicable law, to carry out duties with respect to a dead person or, if necessary, in reasonable anticipation of the person’s death.
FOR CADAVERIC ORGAN, EYE OR TISSUE DONATION PURPOSES – The Fund may use or disclose protected health information in communications with organ procurement organizations or other agencies engaged in the procurement, banking or transplantation of cadaveric organs, eyes or issue for the purpose of facilitating donation and transplantation.
FOR RESEARCH PURPOSES – The Fund may use or disclose protected health information for research purposes, to the extent permitted under the Department of Health and Human Service Regulations Regarding Privacy of Individually Identifiable Health Information.
FOR WORKERS’ COMPENSATION – The Fund may release your health information to the extent necessary to comply with laws related to workers’ compensation or similar programs.
AUTHORIZATION TO USE OR DISCLOSE HEALTH INFORMATION
Other than as stated above, the Fund will not disclose your health information other than with your written authorization. If you authorize the Fund to use or disclose your health information, you may revoke that authorization in writing at any time.
THE “MINIMUM NECESSARY” STANDARD
When using or disclosing protected health information or when requesting protected health information from another covered entity, the Fund will make reasonable efforts not to use, disclose or request more than the minimum amount of protected health information necessary to accomplish the intended purpose of the use, disclosure or request, taking into consideration practical and technological limitations.
However, the “minimum necessary” standard will not apply in the following situations:
YOUR RIGHTS WITH RESPECT TO YOUR HEALTH INFORMATION
You have the following rights regarding your health information that the Fund maintains:
RIGHT TO REQUEST RESTRICTIONS – You may request restrictions on certain uses and disclosures of your health information. You have the right to request a limit on the Fund’s disclosure of your health information to someone involved in the payment of your care. However, the Fund is not required to agree to your request. If you wish to make a request for restrictions, please contact the Contact Person.
RIGHT TO RECEIVE CONFIDENTIAL COMMUNICATIONS – You have the right to request that the Fund communicate with you in a certain way if you feel the disclosure of your health information could endanger you. For example, you may ask that the Fund only communicate with you at a certain telephone number or by email. If you wish to receive confidential communications, please make your request in writing to the Contact Person. The Fund will attempt to honor your reasonable requests for confidential communications.
RIGHT TO INSPECT AND COPY YOUR HEALTH INFORMATION – You have the right to inspect and copy your health information. A request to inspect and copy records containing your health information must be made in writing to the Contact Person. If you request a copy of your health information, the Fund may charge a reasonable fee for copying, assembling costs and postage, if applicable, associated with your request.
RIGHT TO AMEND YOUR HEALTH INFORMATION – If you believe that your health information records are inaccurate or incomplete, you may request that the Fund amend the records. That request may be made as long as the information is maintained by the Fund. A request for an amendment of records must be made in writing to the Contact Person. The Fund may deny the request if it does not include a reason to support the amendment. The request also may be denied if your health information records were not created by the Fund, if the health information you are requesting to amend is not part of the Fund’s records, if the health information you wish to amend falls within an exception to the health information you are permitted to inspect and copy, or if the Fund determines the records containing your health information are accurate and complete.
RIGHT TO AN ACCOUNTING – You have the right to request a list of disclosures of your health information made by the Fund for any reason other than for treatment, payment or health operations. The request must be made in writing to the Contact Person. The request should specify the time period for which you are requesting the information, but may not start earlier than April 14, 2003. Accounting requests may not be made for periods of time going back more than six (6) years. The Fund will provide the first accounting you request during any 12-month period without charge. Subsequent accounting requests may be subject to a reasonable cost-based fee. The Fund will inform you in advance of the fee, if applicable.
RIGHT TO A PAPER COPY OF THIS NOTICE – You have a right to request and receive a paper copy of this Notice at any time, even if you have received this Notice previously or agreed to receive the Notice electronically. To obtain a paper copy, please contact the Contact Person.
DUTIES OF THE FUND
The Fund is required by law to maintain the privacy of your health information as set forth in this Notice and to provide to you this Notice of its duties and privacy practices. The Fund is required to abide by the terms of this Notice, which may be amended from time to time. The Fund reserves the right to change the terms of this Notice and to make the new Notice provisions effective for all health information that it maintains. If the Fund changes its policies and procedures, it will revise the Notice and will provide a copy of the revised Notice to you within 60 days of the change. You have the right to express complaints to the Fund and to the Secretary of the Department of Health and Human Services if you believe that your privacy rights have been violated. Any complaints to the Fund should be made in writing to the Contact Person. The Fund encourages you to express any concerns you may have regarding the privacy of your information. You will not be retaliated against in any way for filing a complaint.
The Fund has designated the following as its contact person for all issues regarding patient privacy and your privacy rights:
Mr. Thomas J. Boehm
Local 734 Welfare Fund
6643 North Northwest Highway
Chicago, IL 60631-1360
Telephone: (773) 594-2810
Fax: (773) 631-3824
This Notice is effective April 14, 2003.
IF YOU HAVE ANY QUESTIONS REGARDING THIS NOTICE, PLEASE CONTACT the Contact Person listed above.