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 PLAN 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:
- Quality assessment and improvement activities.
- Activities designed to improve health or reduce health care costs.
- Clinical guideline and protocol development, case management and care coordination.
- Contacting health care providers and participants with information about treatment alternatives and other related functions.
- Health care professional competence or qualifications review and performance evaluation.
- Accreditation, certification, licensing or credentialing activities.
- Underwriting, premium rating or related functions to create, renew or replace health insurance or health benefits.
- Review and auditing, including compliance reviews, medical reviews, legal services and compliance programs.
- Business planning and development including cost management and planning related analyses and formulary development.
- Business management and general administrative activities of the Fund, including customer service and resolution of internal grievances.
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: Debbie Hill, United Administrative Services, 6800 Santa Teresa Blvd, Ste 100, San Jose CA 95119; phone: (408) 288-4540; fax: (408) 288-4419; email: email@example.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 Debbie Hill, United Administrative Services, 6800 Santa Teresa Blvd, Ste 100, San Jose CA 95119; fax: (408) 288-4419; email: firstname.lastname@example.org. 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 Debbie Hill, United Administrative Services, 6800 Santa Teresa Blvd, Ste 100, San Jose CA 95119; fax: (408) 288-4419; email: email@example.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 to Debbie Hill, United Administrative Services, 6800 Santa Teresa Blvd, Ste 100, San Jose CA 95119; fax: (408) 288-4419; email: firstname.lastname@example.org. 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 Debbie Hill, United Administrative Services, 6800 Santa Teresa Blvd, Ste 100, San Jose CA 95119; fax: (408) 288-4419; email: email@example.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 Debbie Hill, United Administrative Services, 6800 Santa Teresa Blvd, Ste 100, San Jose CA 95119; phone: (408) 288-4400; fax: (408) 288-4419; email: firstname.lastname@example.org.
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 Debbie Hill, United Administrative Services, 6800 Santa Teresa Blvd, Ste 100, San Jose CA 95119; fax: (408) 288-4419; email: email@example.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.
The Fund has designated Debbie Hill as its contact person for all issues regarding patient privacy and your privacy rights. You may contact Debbie Hill at United Administrative Services, 6800 Santa Teresa Blvd, Ste 100, San Jose CA 95119, phone: (408) 288-4540, fax: (408) 288-4419; email: firstname.lastname@example.org.
This Notice is effective April 14, 2003.
IF YOU HAVE ANY QUESTIONS REGARDING THIS NOTICE, PLEASE CONTACT
Debbie Hill, United Administrative Services, 6800 Santa Teresa Blvd, Ste 100, San Jose CA 95119; phone: (408) 288-4540; fax: (408) 288-4419; email: email@example.com.