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|Section 1: Purpose of This Notice and Effective Date|
|Section 2: Your Protected Health Information|
|Section 3: Your Individual Privacy Rights|
|Section 4: The Fund’s Duties|
|Section 5: Your Right to File a Complaint|
|Section 6: If You Need More Information|
|Section 7: Conclusion|
The attached Privacy Notice describes how medical/health information about you may be used and disclosed and how you can get access to this information. Please review it carefully.
We have summarized the Plan’s privacy responsibilities and your rights with respect to your health information on this page. For a complete description of the Plan’s privacy practices, please review the entire attached Notice.
The Plan’s Responsibilities
The Plan is required to:
If you receive health benefits through the Plan you have several rights regarding your personal health information (which rights can also be exercised on your behalf by your legally authorized personal representative), including the following:
The Plan reserves the right to change its privacy practices and to make the new provisions effective for all personal health information the Plan maintains. Should the Plan make material changes, the Plan will post a revised Notice in a clear and prominent location and make the revised Notice available to you.
The Plan will not use or disclose your personal health information without your written permission (known as an authorization), except as described in this Notice. The effective date of this privacy notice is 9/23/13.
If you have questions or would like further information regarding your privacy rights, please contact the Plan’s Privacy Official at the following address:
Mr. Scott Trivigno, Privacy Official
I.A.T.S.E. National Health & Welfare Fund
417 Fifth Avenue, 3rd Floor
New York, NY 10016-2204
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.
This Privacy Notice applies to the offices of the I.A.T.S.E. National Health and Welfare Fund (the “Fund), and the services that the Fund provides through Empire BlueCross BlueShield, Triple S, Delta Dental, SIDS or Caremark, The Fund’s insurers (currently Davis Vision), and mail order pharmacy provider will send you a notice of their privacy procedures separately.
Effective date: The effective date of this Notice is September 23, 2013. This Notice is required by law: The Fund is required by law to take reasonable steps to ensure the privacy of your personally identifiable health information and to inform you about:
Protected Health Information (PHI) Defined
The term “Protected Health Information” (PHI) includes all individually identifiable health information related to an individual’s past, present or future physical or mental health condition or to payment for health care. PHI includes information maintained by the Fund in oral, written, or electronic form.
When the Fund May Disclose Your PHI
Under the law, the Fund may disclose your PHI without your consent or authorization, or without giving you the opportunity to agree or object, in the following cases:
When the Disclosure of Your PHI Requires Your Written Authorization
Although the Fund does not routinely obtain psychotherapy notes, it must generally obtain your written authorization before the Fund will use or disclose psychotherapy notes about you. However, the Fund may use and disclose such notes when needed by the Fund to defend itself against litigation filed by you. Psychotherapy notes are separately filed notes about your conversations with your mental health professional during a counseling session. They do not include summary information about your mental health treatment.
Although the Fund does not routinely sell PHI or use it for marketing purposes, it must obtain your written authorization before it may sell your PHI or use it for marketing purposes.
When You Can Object and Prevent the Fund from Using or Disclosing PHI
The Fund will disclose to your spouse/domestic partner the portion of your PHI that is directly relevant to your spouse or domestic partner’s involvement with your care or payment for that care unless you notify the Fund’s Privacy Official in writing (contact information below) that you object to our sharing that information with your spouse or domestic partner. In an emergency or if you become incapacitated, the Fund may also disclose your PHI to other family members, relatives or close friends under certain circumstances as permitted in the Fund’s procedures, unless you have previously notified the Fund’s Privacy Official in writing that you do not want your information shared under those circumstances.
If you want the Fund to disclose routinely your PHI to persons other than your spouse or domestic partner (e.g., your children) then you must complete an authorization form designating that person as authorized to receive your PHI. Authorization forms are available from the Privacy Official at the Fund office.
Other Uses or Disclosures
The Fund may contact you to provide you information about treatment alternatives or other health-related benefits and services that may be of interest to you.
You May Request Restrictions on PHI Uses and Disclosures You may request the Fund to:
The Fund, however, is not required to agree to your request except if the use or disclosure is for purposes of carrying out payment or health care operations, is not otherwise required by law, and the PHI pertains solely to a health care item or service that has been paid for in full by you or somebody other than the Fund.
You or your personal representative will be required to complete a form to request restrictions on uses and disclosures of your PHI. Make such requests to:
I.A.T.S.E. National Health and Welfare Fund
417 Fifth Avenue, 3rd Floor
New York, NY 10016-2204
Toll-free: 800-456-Fund (3863)
You May Request Confidential Communications
The Fund will accommodate your reasonable request to receive communications of PHI confidentially by alternative means or solely at alternative locations (e.g., mailing information somewhere other than your home address) where the request includes a statement that disclosure using the Fund’s regular communications procedures could endanger you. You or your personal representative will be required to complete a form to request confidential communications of your PHI. Make such requests to the Fund’s Privacy Official.
You May Inspect and Copy PHI
You have a right to inspect and obtain a copy of your PHI contained in a “designated record set,” defined below, for as long as the Fund maintains the PHI.
The Fund must provide the requested information within 30 days if the information is maintained on site or within 60 days if the information is maintained offsite. A single 30 day extension is allowed if the Fund is unable to comply with the deadline.
You or your personal representative will be required to complete a form to request access to the PHI in your designated record set. A reasonable fee may be charged. Requests for access to PHI should be made to the Fund’s Privacy Official. If access is denied, you or your personal representative will be provided with a written denial setting forth the basis for the denial, a description of how you may exercise your review rights and a description of how you may complain to Fund and HHS.
Designated Record Set: includes your medical records and billing records that are maintained by or for a covered health care provider. Records include enrollment, payment, billing, claims adjudication and case or medical management record systems maintained by or for a health Fund or other information used in whole or in part by or for the covered entity to make decisions about you. Information used for quality control or peer review analyses and not used to make decisions about you is not included.
You Have the Right to Amend Your PHI
You have the right to request that the Fund amend your PHI or a record about you in a designated record set for as long as the PHI is maintained in the designated record set subject to certain exceptions. See the Fund’s Right to Amend Policy (available on request from the Fund’s Privacy Official) for a list of exceptions.
The Fund has 60 days after receiving your request to act on it. The Fund is allowed a single 30-day extension if the Fund is unable to comply with the 60-day deadline. If the Fund denied your request in whole or part, the Fund must provide you with a written denial that explains the basis for the decision. You or your personal representative may then submit a written statement disagreeing with the denial and have that statement included with any future disclosures of that PHI.
You should make your request to amend PHI to the Fund’s Privacy Official. You or your personal representative will be required to complete a form to request amendment of the PHI.
You Have the Right to Receive an Accounting of the Fund’s PHI Disclosures
At your request, the Fund will also provide you with an accounting of certain disclosures by the Fund of your PHI made after April 14, 2003. We do not have to provide you with an accounting of disclosures related to treatment, payment for treatment, or health care operations, or disclosures made to you or authorized by you in writing. See the Fund’s Accounting for Disclosure Policy (available on request from the Fund’s Privacy Official) for the complete list of disclosures for which an accounting is not required.
The Fund has 60 days to provide the accounting. The Fund is allowed an additional 30 days if the Fund gives you a written statement of the reasons for the delay and the date by which the accounting will be provided. If you request more than one accounting within a 12-month period, the Fund will charge a reasonable, cost-based fee for each subsequent accounting.
Your Personal Representative
You may exercise your rights through a personal representative. Except as provided below in connection with parents of unemancipated minor children, your personal representative will be required to produce evidence of authority to act on your behalf before the personal representative will be given access to your PHI or be allowed to take any action for you. Proof of such authority includes a completed, signed and approved Appointment of Personal Representative form. You may obtain this form by calling the Fund Office.
The Fund retains discretion to deny access to your PHI to a personal representative to provide protection to those vulnerable people who depend on others to exercise their rights under these rules and who may be subject to abuse or neglect.
The Fund will recognize certain individuals as personal representative without completion of an Appointment of Personal Representative form. For example, the Fund will consider a parent or guardian as the personal representative of an unemancipated minor unless applicable state law requires otherwise. Unemancipated minors may, however, request that the Fund restrict information that goes to family members as described above at the beginning of Section 3 of this Notice. Other documentation that may substitute for this form would include other official legal documentation that demonstrates that under relevant state law the representative is authorized to make health care decisions for you (e.g., appointment as a legal guardian, or a health care power of attorney).
You should also review the Fund’s Policy and Procedure for the Recognition of Personal Representatives (available on request from the Fund’s Privacy Official) for a more complete description of the circumstances where the Fund will consider an individual to be your personal representative for purposes of exercising your rights under this Privacy Notice.
Maintaining Your Privacy
The Fund is required by law to maintain the privacy of your protected health information, provide you with certain rights with respect to your protected health information, provide you with a copy of this Notice of our legal duties and privacy practices with respect to your protected health information, and follow the terms of this Notice that is currently in effect. Furthermore, we are required to notify you if your protected health information has been breached.
This Notice is effective beginning on September 23, 2013 and the Fund is required to comply with the terms of this notice. However, the Fund reserves the right to change its privacy practices and this Notice and to apply the changes to any PHI received or maintained by the Fund prior to that date. If a privacy practice is materially changed, a revised version of this Notice will be provided to you and to all past and present participants and beneficiaries for whom the Fund still maintains PHI.
The Notice will be provided via mail to all named participants. Any other person, including dependents of named participants, may receive a copy upon request.
Any revised version of this Notice will be distributed within 60 days of the effective date of any material change to the Fund’s policies on:
Disclosing Only the Minimum Necessary Protected Health Information
When using or disclosing PHI or when requesting PHI from another covered entity, the Fund will make reasonable efforts not to use, disclose or request more than the minimum amount of PHI 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:
This notice does not apply to information that has been de-identified. De-identified information is information that:
If you believe that your privacy rights have been violated, you may file a written complaint with the Fund in care of the Fund’s Privacy Official. The Fund will not retaliate against you for filing a complaint.
You may also file a complaint with:
Office for Civil Rights
U.S. Department of Health & Human Services
Jacob Javits Federal Building
26 Federal Plaza, Suite 3312 New York, NY 10278
If you have any questions regarding this notice or the subjects addressed in it, you may contact the Privacy Official at the Fund Office.
PHI use and disclosure by the Fund is regulated by the federal Health Insurance Portability and Accountability Act, known as HIPAA. You may find these rules at 45 Code of Federal Regulations Parts 160 and 164. This notice attempts to summarize the regulations. The regulations will supersede this notice if there is any discrepancy between the information in this Notice and the regulations.