THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED OR DISCLOSED AND
HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
HOW THE ELECTRICAL WORKERS LOCAL 332 TRUST FUND (the “FUND”) USES AND DISCLOSES
INFORMATION.
The Fund may use 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 use in making or obtaining payment for your care and for conducting health care operations. The Fund has
established a policy to protect against unnecessary disclosure of your health information.
THE FOLLOWING SUMMARIZES UNDER WHAT CIRCUMSTANCES AND FOR WHAT PURPOSES YOUR HEALTH INFORMATION MAY BE USED AND DISCLOSED.
For Payment Purposes. The Fund may use or disclose your health information to make payment to or collect
payment from third parties, such as other health plans or providers, for the care you receive. For example, the
Fund may provide information regarding your coverage to other plans to coordinate payment of benefits.
For Health Care Operations. The Fund may use or disclose health information for its own operations to
administer the Fund and to provide coverage and services to Fund participants. Health care operations include
the following:
For example, the Fund may use your health information to conduct case management, quality improvement and
utilization review, and provider credentialing activities, or to resolve customer service complaints.
For Treatment Alternatives. The Fund may use and disclose your health information to provide you advice on
treatment options or alternatives that may be of interest to you.
For Distribution of Health-Related Benefits Services. The Fund may use or disclose your health
information to provide you with information on health related services and benefits that may be of interest to you.
For Disclosure to the Plan Sponsors. The Fund may disclose your health information to the Plan Sponsors
for plan administration functions performed on behalf of the Fund. The Fund may also provide summary health
information to the Plan Sponsors in connection with the solicitation of premium bids from health insurers or to
modify, amend or terminate the Fund’s health plan. The Fund may also disclose to the Plan Sponsors
information on whether you are participating in the Plan.
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.
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.
For Worker's Compensation. The Fund may release your health information to the extent necessary to
comply with laws related to worker's compensation or similar programs.
AUTHORIZATION TO USE OR DISCLOSE HEALTH INFORMATION
Except 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.
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: Jean P. Sukovez, United Administrative Services, 1120 S.
Bascom Avenue, San Jose, CA 95128, phone: (408) 288-4430, fax: (408) 288-4419, email: jsukovez@uastpa. com.
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 Jean P. Sukovez, United
Administrative Services, 1120 S. Bascom Avenue, San Jose, CA 95128, fax: (408) 288-4419, email: jsukovez@uastpa.com. 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
Jean P. Sukovez, United Administrative Services, 1120 S. Bascom Avenue, San Jose, CA 95128, fax: (408) 288-
4419, email: jsukovez@uastpa.com. 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 Jean P.
Sukovez, United Administrative Services, 1120 S. Bascom Avenue, San Jose, CA 95128, fax: (408) 288-4419,
email: jsukovez@uastpa.com. 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 certain disclosures of your health information
that the Fund is required to keep a record of under the Privacy Rule, such as disclosures for public purposes
authorized by law or disclosures that are not in accordance with the Fund's privacy policies and applicable law.
The request must be made in writing to Jean P. Sukovez, United Administrative Services, 1120 S. Bascom
Avenue, San Jose, CA 95128, fax: (408) 288-4419, email: jsukovez@uastpa.com. 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 Jean P. Sukovez, United Administrative Services, 1120 S. Bascom Avenue,
San Jose, CA 95128, fax: (408) 288-4419, email: jsukovez@uastpa.com.
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, the Fund 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 complain 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 Jean P. Sukovez, United Administrative Services, 1120 S. Bascom Avenue,
San Jose CA, 95128, fax: (408) 288-4419, email jsukovez@uastpa.com. The Fund encourages you to state any
concerns you may have regarding the privacy of your information. You will not be retaliated against in any way
for filing a complaint.
CONTACT PERSON
The Fund has designated the Jean P. Sukovez as its contact person for all issues regarding patient privacy and
your privacy rights. You may contact this person at Jean P. Sukovez at United Administrative Services, 1120 S.
Bascom Avenue, San Jose CA 95128, phone: (408) 288-4430, fax: (408) 288-4419 email: jsukovez@uastpa. com .
EFFECTIVE DATE
This Notice is effective April 14, 2003.
IF YOU HAVE ANY QUESTIONS REGARDING THIS NOTICE, PLEASE CONTACT
Jean P. Sukovez, United Administrative Services, 1120 S. Bascom Avenue, San Jose, CA 95128, phone: (408) 288-4430, fax: (408) 288- 4419, email: jsukovez@uastpa.com.