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.
USE
AND DISCLOSURE OF HEALTH INFORMATION
The I.A.T.S.E. Local #16 Health & Welfare Trust Fund ["Health Plan"] 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 Health Plan has established a policy to guard against unnecessary disclosure of your health information.
THE FOLLOWING IS A SUMMARY OF THE CIRCUMSTANCES AND PURPOSES FOR WHICH YOUR HEALTH INFORMATION MAY BE USED AND DISCLOSED:
To Make or Obtain Payment. The Health Plan 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 Health Plan may provide information regarding your coverage or health care treatment to other health plans to coordinate payment of benefits.
The Health Plan may also disclose health information over the telephone to your spouse, another family member, or a personal representative (such as a Union business agent or Employer representative), for purposes of making or obtaining information about treatment or claims if you provide your oral authorization to the Health Plan to speak to this person on your behalf. If you do not wish the Health Plan to release your health information to your spouse, family member or personal representative without prior written authorization, please follow the instructions under the Right to Make Restrictions found in this notice.
To Conduct Health Care Operations. The Health Plan may use or disclose health information for its own operations to facilitate the administration of the Health Plan and as necessary to provide coverage and services to all of the Health Plan's participants. For example, the Health Plan may use your health information to conduct case management, quality improvement and utilization review, and provider credentialing activities or to engage in customer service and grievance resolution activities.
For Treatment. The Health Plan does not provide treatment. However, the Health Plan may use or disclose your health information to support treatment and the management of your care. For example, the Health Plan may disclose that you are eligible for benefits to a health care provider who contacts the Health Plan to verify your eligibility.
For Treatment Alternatives. The Health Plan 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 Health Plan may use or disclose your health information to provide you information on health-related benefits and services that may be of interest to you.
Public Health Risks. The Health Plan may disclose medical information about you for public health activities. These activities generally include the following:
· To prevent or control disease, injury or disability;
· To report births and deaths;
· To report child abuse or neglect;
· To report reactions to medications or problems with products;
· To notify people of recalls of products they may be using;
· To notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition;
· To notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect or domestic violence. Health Plan will only make this disclosure if you agree or when required or authorized by law.
For Disclosure to the Plan Sponsor. The Health Plan may disclose your health information to the plan sponsor for plan administration functions performed by the plan sponsor on behalf of the Health Plan. The Health Plan also may provide summary health information to the plan sponsor so that the plan sponsor may solicit premium bids from other health plans or modify, amend or terminate the plan.
When Legally Required. The Health Plan will disclose your health information when it is required to do so by any federal, state or local law.
Organ and Tissue Donation. If you are an organ donor, the Health Plan may release medical information to organizations that handle organ procurement or organ, eye or tissue transplantation or to an organ donation bank, as necessary to facilitate organ or tissue donation and transplantation.
To Conduct Health Oversight Activities. The Health Plan 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 Health Plan, 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 Health Plan 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 Health Plan 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 Health Plan may disclose your health information to a law enforcement official for certain law enforcement purposes, including, but not limited to, if the Health Plan has a suspicion that your death was the result of criminal conduct or in an emergency to report a crime.
To Coroners, Medical Examiners and Funeral Directors. The Health Plan may release your health information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. The Health Plan may also release your health information to funeral directors as necessary to carry out their duties.
In the Event of a Serious Threat to Health or Safety. The Health Plan may, consistent with applicable law and ethical standards of conduct, disclose your health information if the Health Plan, 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. Any disclosure would be to someone able to help prevent the threat.
For Specified Government Functions. In certain circumstances, federal regulations require Health Plan 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 Health Plan 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
Other than as stated above, the Health Plan will not disclose your health information other than with your written authorization. If you authorize the Health Plan 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 Health Plan 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 Health Plan's disclosure of your health information to
someone involved in the payment of your care.
However, the Health Plan is not required to agree to your request. If you wish to make a request for restrictions,
please the HIPAA Privacy Officer at
(415) 243-0165.
Right to Receive Confidential Communications. You have the right to request that the Health Plan communicate with you in a certain way if you feel the disclosure of your health
information could endanger you. You may be required to provide a statement that disclosure of your health information could endanger you. For example, you may ask that the Health Plan 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 HIPAA Privacy Officer, IATSE Local #16 Health & Welfare Trust Fund, 240 Second Street, San Francisco, CA 94105. Fax (415) 243-0333. The Health Plan 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 HIPAA Privacy Officer, IATSE Local #16 Health & Welfare Trust Fund, 240 Second Street, San Francisco, CA 94105. Fax (415) 243-0333. If you request a copy of your health information, the Health Plan may charge a reasonable fee for copying, assembling costs and postage, if applicable, associated with your request. The Health Plan may deny your request in limited situations.
Right to Amend Your Health Information. If you believe that your health information records are inaccurate or incomplete, you may request that the Health Plan amend the records. That request may be made as long as the Health Plan maintains the information. A request for an amendment of records must be made in writing to HIPAA Privacy Officer, IATSE Local #16 Health & Welfare Trust Fund, 240 Second Street, San Francisco, CA 94105. Fax (415) 243-0333. The Health Plan 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 Health Plan, if the health information you are requesting to amend is not part of the Health Plan'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 Health Plan 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 Health Plan for any reason other than for treatment, payment or health operations. The request must be made in writing to HIPAA Privacy Officer, IATSE Local #16 Health & Welfare Trust Fund, 240 Second Street, San Francisco, CA 94105. Fax (415) 243-0333. 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 Health Plan 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 Health Plan 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 HIPAA Privacy Officer, IATSE Local #16 Health &
Welfare Trust Fund, 240 Second Street, San Francisco, CA 94105. Fax (415) 243-0333. You also may obtain a copy of the
current version of the Health Plan's Notice at its Web site, www.local16.org.
DUTIES OF HEALTH PLAN
The Health Plan 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 Health Plan is required to abide by the terms of this Notice, which may be amended from time to time. The Health Plan 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 Health Plan changes its policies and procedures, the Health Plan 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 Health Plan 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 Health Plan should be made in writing to The Board Of Trustees, IATSE Local #16 Health & Welfare Trust Fund, 240 Second Street, San Francisco, CA 94105. The Health Plan 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.
CONTACT PERSON
The Health Plan has designated Wynne
Aldana, HIPAA Privacy Officer, as its contact person for all issues
regarding patient privacy and your privacy rights. You may contact her c/o IATSE Local #16
Health & Welfare Trust Fund, 240 Second Street, San Francisco, CA 94105. Telephone Number: (415) 243-0165.
EFFECTIVE DATE
This Notice is effective April 14, 2003.
IF YOU HAVE ANY QUESTIONS REGARDING THIS NOTICE, PLEASE CONTACT Wynne Aldana, Privacy Officer, or Vivian Mori, IATSE Local #16 Health & Welfare Trust Fund, 240 Second Street, San Francisco, CA 94105. Fax (415) 243-0333.
Sincerely,
THE
BOARD OF TRUSTEES