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.
Effective Date of Notice: April 14, 2003.
General Privacy Rules:
The Welfare Plan (“Plan”) is required by law to maintain the privacy of protected health information and to inform you about:
· the Plan’s uses and disclosures of protected health information;
· your privacy rights with respect to such information;
· the Plan’s duties with respect to such information;
· the person or office to contact for further information about the Plan’s privacy practices.
Section 1. Notice of Uses and Disclosures
(a) Uses and disclosures to carry out treatment, payment and health care operations without your consent or authorization. The Plan and its business associates will use protected health information without your consent, authorization or opportunity to agree or object to carry out “treatment, payment and health care operations” as defined below.
(i) Treatment is the provision, coordination or management of health care and related services. For example, your pharmacy may contact your treating physician to refill your prescription for medication.
(ii) Payment includes but is not limited to actions to make coverage determinations and payment. For example, the Plan may tell a doctor whether you are eligible for coverage.
(iii) Health care operations include but are not limited to quality assessment and improvement, reviewing competence or qualifications of health care professionals, underwriting, premium rating and other insurance activities relating to creating or renewing insurance contracts and related business services. For example, the Plan may use information about your claims to refer you to a disease management program, project future benefit costs and audit the accuracy of its claims processing functions.
(b) Individual. The Plan will disclose to you, or your duly authorized personal representative, your own protected health information.
(c) Department of Health and Human Services. The Plan will disclose to the Secretary of the U.S. Department of Health and Human Services your protected health information if required by it to investigate or determine the Plan’s compliance with its privacy regulations.
(d) Other uses and disclosures for which consent, authorization or opportunity to object is not required. Use and disclosure of your protected health information is allowed without your consent, authorization or request under the following circumstances:
(i) When required for judicial or administrative proceedings, provided certain conditions are met. Those conditions include that satisfactory assurances are given to the Plan that the requesting party has made a good faith attempt to provide written notice to you, the notice provided sufficient information about the proceeding to permit you to raise an objection and no objections were raised or were resolved in favor of disclosure by the court or tribunal.
(ii) When required by law.
(iii) When permitted for purposes of public health activities.
(iv) To a public health oversight agency for oversight activities authorized by law.
(v) When required for law enforcement purposes.
(vi) When required to be given to a coroner or medical examiner for the purpose 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, as necessary to carry out their duties with respect to the decedent.
(vii) When consistent with applicable law and standards of ethical conduct if the Plan, in good faith, believes the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public.
(viii) When authorized by and to the extent necessary to comply with workers’ compensation or other similar programs established by law.
(e) Uses and disclosures that require that you be given an opportunity to agree or disagree prior to the use or disclosure. Disclosure of your protected health information to family members, other relatives and your close personal friends is allowed if the information is directly relevant to the family or friend’s involvement with your care or payment for that care and you have either agreed to the disclosure or have been given an opportunity to object and have not objected.
(f) Uses and disclosures that require your written authorization.
(i) In general, the Plan will obtain a written authorization before using or disclosing your protected health information whenever it is required to do so under the privacy rules. Your written authorization generally will be obtained before the Plan will use or disclose psychotherapy notes about you from your psychotherapist. The Plan may use and disclose psychotherapy notes when needed by the Plan to defend against litigation filed by you. The Plan will not disclose to third parties the results of genetic testing in a manner which includes individually identifying characteristics without your written authorization.
(ii) The Plan may require your authorization to disclose protected health information, even to carry out treatment, payment or health care operations, to certain individuals or organizations. For example, if your union representative is helping you with a claim the Plan may require you to sign an authorization form before it will disclose protected health information to that person.
Section 2. Rights of Individuals
(a) Right to Request Restrictions on Protected Health Information Uses and Disclosures. You may request the Plan to restrict uses and disclosures of your protected health information to carry out treatment, payment or health care operations, or to restrict uses and disclosures to family members, relatives, friends or other persons identified by you who are involved in your care or payment for your care. However, the Plan is not required to agree to your request.
The Plan will accommodate reasonable requests to receive communications of protected health information by alternative means or at alternative locations. You or your personal representative will be required to complete a form to request restrictions on uses and disclosures of your protected health information. Such requests should be made to the Plan Manager identified in Section 5.
(b) Right to Inspect and Copy Protected Health Information. You have a right to inspect and obtain a copy of your protected health information for as long as the Plan maintains the protected health information. The requested information will be provided 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 Plan is unable to comply with the deadline.
You or your personal representative will be required to complete a form to request access to the protected health information. Requests for access to protected health information should be made to the Plan Manager. If access is denied, you and your personal representative will be provided with a written denial setting forth the basis for the denial, a description of how you may exercise rights to review and a description of how you may complain to the Secretary of the U.S. Department of Health and Human Services.
(c) Right to Amend Protected Health Information. You have the right to request that the Plan Manager amend your protected health information or a record about you for as long as the protected health information is maintained by the Plan. You or your personal representative will be required to complete a form to request amendment of the protected health information.
The Plan has 60 days after the request is made to act on the request. A single 30-day extension is allowed if the Plan is unable to comply with the deadline. If the request is denied in whole or part, the Plan must provide you with a written denial that explains the basis for the denial. 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 your protected health information.
(d) The Right to Receive an Accounting of Protected Health Information Disclosures. At your request, the Plan will also provide you with an accounting of disclosures by the Plan of your protected health information during the six years prior to the date of your request. However, such accounting need not include protected health information disclosures made:
(i) to carry out treatment, payment or health care operations;
(ii) to individuals about their own protected health information; or
(iii) prior to April 14, 2003.
If the accounting cannot be provided within 60 days, an additional 30 days is allowed if the individual is given 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 Plan will charge a reasonable, cost-based fee for each subsequent accounting.
(e) Personal Representatives. You may exercise your rights through a personal representative recognized by law. Your personal representative will be required to produce evidence of his/her authority to act on your behalf before that person will be given access to your protected health information or allowed to take any action for you. The Plan retains discretion to deny access to your protected health information 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. This also applies to personal representatives of minors.
Section 3. The Plan’s Duties
(a) General Duty. The Plan is required to comply with the terms of this notice. However, the Plan reserves the right to change its privacy practices and to apply the changes to any protected health information received or maintained by the Plan prior to that date. If a privacy practice is changed, a revised version of this notice will be provided to all past and present participants and beneficiaries for whom the Plan still maintains protected health information. The revised notice will be mailed to all active and retired plan participants. Any revised version of this notice will be distributed within 60 days of the effective date of any material change to the uses or disclosures, the individual’s rights, the duties of the Plan or other privacy practices stated in this notice.
(b) Minimum Necessary Standard. When using or disclosing protected health information or when requesting protected health information from another covered entity, the Plan 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:
(i) disclosures to or requests by a health care provider for treatment;
(ii) uses or disclosures made to the participant or beneficiary;
(iii) disclosures made to the Secretary of the U.S. Department of Health and Human Services;
(iv) uses or disclosures that are required by law; and
(v) uses or disclosures that are required for the Plan’s compliance with legal regulations.
(c) De-Identified Information. This notice does not apply to information that has been de-identified. De-identified information 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 the individual.
In addition, the Plan may use or disclose “summary health information” for obtaining premium bids or modifying, amending or terminating the group health plan, which summarizes the claims history, claims expenses or type of claims experienced by individuals for whom a plan sponsor has provided health benefits under a group health plan; and from which identifying information has been deleted in accordance with HIPAA.
Section 4. Your Right to File A Complaint With the Plan or the HHS Secretary
If you believe that your privacy rights have been violated, you may complain to the Plan in care of the Plan Manager. You may file a complaint with the Secretary of the U.S. Department of Health and Human Services, Hubert H. Humphrey Building, 200 Independence Avenue S.W., Washington, D.C. 20201. The Plan will not retaliate against you for filing a complaint.
Section 5. Whom to Contact at the Plan for More Information
If you have any questions regarding this notice or the subjects addressed in it, you may contact the Privacy Officer:
Jean P. Sukovez
United Administrative Services
1120 Bascom Avenue
San Jose, CA 95128-3590
Phone: (408) 288-4430
Fax: (408) 288-4419
jsukovez@uastpa.com