The Teamsters Local 805 HIPPA Privacy Notice

April 2007

Dear Local 805 Member:

Our Welfare Plan is required by Federal Law to periodically notify members about the availability of its Notice of Privacy Practices. This notice describes how medical information (Protected Health Information, “PHI”) about you may be used and disclosed and how you can get access to this information.

It has always been the policy of the Local 805 Welfare Fund not to use or disclose any of your personal medical information unless the person identified in the PHI consents to or authorized the use or disclosure, or if the Privacy Rules specifically allow such use or disclosure.

You do not have to take any action as a result of this notice. The Notice of Privacy Practices is posted below. If you would like to obtain a paper copy of the Notice of Privacy Practices please contact:

Privacy Officer
Local 805 Welfare Fund
44-61 11th Street, 3rd Floor
Long Island City, NY 11101

Sincerely,

Rod Gorham
Fund Administrator

IN ACCORDANCE WITH NEW FEDERAL LAWS THE LOCAL 805 WELFARE FUND IS REQUIRED TO INFORM ALL PARTICIPANTS OF THE POLICIES GOVERNING THE PRIVACY AND PERMITTED USED OF YOUR PROTECTED HEALTH INFORMATION

THE LOCAL 805 WELFARE FUND NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY

INTRODUCTION

The Local 805 Welfare Fund (“the Fund”) is a covered entity within the meaning of the Health Insurance Portability and Accountability Act of 1966, commonly known as “HIPAA.” Under HIPAA, the Fund is legally required to provide you with notice of our legal duties and privacy practices with respect to Protected Health Information (“PHI). PHI includes any individually identifiable information that relates to your physical or mental health, the health care that you have received, or payment for your health care, including your name, address, date of birth and Social Security number.

We are legally required to maintain the privacy of your PHI. The Primary purpose of this notice is to describe how we may use and disclose your PHI in connection with your receiving treatment, our payment for such treatment and for health care operations. This notice also describes your right to access and control your PHI.

We are required to abide by the terms of this Notice of Privacy Practices (“Notice”). However, we reserve the right to change the terms of this or any subsequent Notice at any time. If we elect to make a change, the revised Notice will be effective for all PHI that we maintain at that time. Within 60 days of any material revision of our privacy practices we will distribute a new Notice. Additionally, you may contact the Fund Directly at any time to obtain a copy of the most recent Notice.

This Notice is effective April 14, 2003.

PERMITTED USES AND DISCLOSURES

We use and may disclose your PHI in connection with your receiving treatment, our payment for such treatment and for health care operations, except with respect to psychotherapy notes in which care we will require an authorization to use or disclose such notes except in the care of a lawsuit against us. Generally we will make every effort to disclose only the minimum necessary amount of PHI to achieve the purpose of the use or disclosure.

Treatment: means the provision, coordination or management of your health care. As a health Fund, while we do not provide treatment, we may use or disclose our PHI to support the provision, coordination or management of your care. For example, we may disclose the fact that you are eligible for benefits to a provider who contacts us to verify your eligibility.

Payment: means activities in connection with processing claims for your health care. We may need to use or disclose your PHI to determine eligibility for coverage, medical necessity and for utilization review activities. For example, we could disclose your PHI to a physician engaged by the Fund for their medical expertise in order to help us determine medical necessity and eligibility for coverage.

We may also disclose your PHI to third parties who are known as “Business Associates” that perform various activities (e.g., hospital pre-authorization, care management) for us. In such circumstances, we will have a written contract with the Business Associate, which require the Business Associate to protect the privacy of your PHI.

Health Care Operations: generally means general administrative and business functions that the Fund must perform in order to function as a health Fund. For example, we may need to review your PHI as part of the Fund’s efforts to uncover instances of provider abuse and fraud.

Reminders: We may use your PHI to provide you with reminders. For example, we may use your child’s date of birth to remind you that you may purchase continuation coverage for your 19 year old child who would otherwise lose coverage under the Fund.

Treatment Alternatives: We may use your PHI to inform you about treatment alternatives.

Health Related Benefits and Services: We may use or disclose your PHI to inform you about other health-related benefits and services that may be of interest to you.

Disclosure to Trustees of the Fund: We may disclose your PHI to Trustees in connection with appeals that you file following a denial of benefit claim or a partial payment. In addition, any Trustee may receive PHI if you request that Trustee to assist you in your filing or perfecting a claim for benefits under the Fund. Trustees may also receive PHI if necessary for them to fulfill their fiduciary duties with respect to the Fund. Such disclosures will be the minimum necessary to achieve the purpose of the use or disclosure. In accordance with the Fund documents, the Trustees must agree not to use or disclose PHI other that as permitted in this Notice or as required by law, not to use or disclose the PHI with respect to any employment-related actions or decisions, or with respect to any other benefit Fund maintained by the Trustee.

Others Involved In Your Health Care Or Payment For Your Health Care: We may disclose to a member of your family PHI that is directly relevant to that person’s PHI to a close personal fiend or any other person that you identify to us a s entitled to receive PHI. Contact the Fund to obtain the appropriate form to identify the people who may receive this information.

We may also disclose your PHI to any authorized public or private entities assisting in disaster relief efforts.

Required By Law: We may use or disclose our PHI to the extent that we are required to do so by federal, state, or local law. You will be notified, if required by law, or any such uses or disclosures

Public Health: We may disclose your PHI for public health purposes to a public health authority that is permitted by law to collect or receive the information. The disclosure will be made for the purpose of preventing or controlling disease (including communicable diseases), injury or disability. If directed by the public health authority, we may also disclose your PHI to a foreign government agency that is collaborating with the public health authority.

Health Oversight: We may disclose your PHI to a health oversight agency for activities authorized by law, such as audits, investigations, inspections and legal actions. Oversight agencies seeking this information include government agencies that oversee the health care system, government benefit programs, other government regulatory programs and civil rights laws.

Abuse or Neglect: We may disclose your PHI to any public health authority authorized by law to receive reports of child abuse or neglect. In addition, if we reasonably believe that you have been a victim of abuse, neglect or domestic violence we may disclose your PHI to the governmental entity or agency authorized to receive such information. In this case, the disclosure will be made consistent with the requirements of applicable federal and state laws. We will promptly inform you that such a disclosure has been or will be made, unless we reasonably believe that informing you would place you at risk of serious harm, or we would be informing a personal representative of yours who we reasonably believed is responsible for the abuse, neglect, or injury.

Food and Drug Administration: Our Prescription Benefits Manager may disclose your PHI to a person or company subject to the jurisdiction of the food and Drug Administration (FDA) with respect to an FDA-regulated product or activity for which that person has responsibility, for the purpose of activities related to the quality, safety or effectiveness of such FDA-regulated product or activity.

Legal Proceedings: We may disclose your PHI in the course of any judicial or administrative processing, in response to an order of a court or administrative tribunal. In addition, in response to a subpoena, discovery request or other lawful process that is not accompanies by a court order, we will disclose your PHI only upon receipt of an authorization signed by the individual who is the subject of the PHI.

Law Enforcement: we may also disclose your PHI, if requested by a law enforcement official as part of certain law enforcement activities.

Coroners, Funeral Directors, and Organ Donation: We may disclose your PHI to a corner or medical examiner for identification purposes, determining cause of death or other duties authorized by law. We may also disclose your PHI to a funeral director, as authorized by law, in order to permit the funeral director to carry out his/her duties. We may disclose such information in reasonable anticipation of death. PHI may be used and disclosed for cadaveric organ, eye or tissue donation and transplantation purposes.

Research: The law permits us to disclose your PHI to researchers when their research has been approved by an institutional review board that has established protocols to ensure the privacy of your PHI, but it is the Fund’s policy not to make any such disclosure.

Criminal Activity: Consistent with applicable federal and state laws, we may disclose your PHI, if we believe that the use or disclosure is necessary to prevent or lesson a serious and imminent threat to the health or safety of a person or the public. We may also disclose PHI if it is necessary for law enforcement authorities to identify or apprehend an individual.

Military Activity and National Security: When the appropriate conditions apply, we may use or disclose PHI of individuals who are Armed Forces personnel (1) for activities deemed necessary by military command authorities; or (2) to a foreign military authority if you are a member of that foreign military service. We may also disclose your PHI to authorized federal officials conducting national security and intelligence activities including the protection of the President.

Workers’ Compensation: We may disclose your PHI to comply with workers’ compensation laws and other similar legally established programs.

Inmates: If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may disclose your PHI to the institution or law enforcement official if the PHI is necessary for the institution to provide you with health care; to protect the health and safety of you or others, or for the security of the correctional institution.

Required Uses and Disclosures: We must make disclosures to you and to the Secretary of the U.S. Department of Health and Human Services to investigate or determine our compliance with the federal regulations regarding privacy.

Authorization Required For Other Uses and Disclosures of our PHI: Other uses and disclosures of your PHI will be made only with your written authorization, unless otherwise permitted by law as described above. If you authorize us to use or disclose your PHI, you may revoke that authorization, in writing, at any time, except to the extent that we have already taken action based upon the authorization. Thereafter we will no longer use or disclose your PHI for the reasons covered by your written authorization.

YOUR RIGHTS

Right to Inspect And Copy: As long as we maintain your PHI, you may inspect and obtain a copy that is contained in a Designated Record Set. “Designated Record Set” means a group of records that comprise the enrollment, payment claims adjudication, case or medical management record systems maintained by or for the Fund.

Pursuant to federal law, there are certain records which you may not inspect or copy such as psychotherapy notes, information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding.

We may decide to deny access to your PHI. Depending on the circumstances, that decision to deny access may be reviewable by a licensed health professional who was not involved in the initial denial of access and who has been designated by the Fund to act as a reviewing official.

To request access to inspect and/or obtain a copy of your PHI in a specific designated record set, you must submit your request in writing to our Privacy Officer at the address below. If you request a copy, please indicate in which form you want to receive it (i.e., paper or electronic), or if you want a summary or explanation of your PHI in lieu of receiving access to it. We shall impose a fee to cover the costs of copying and postage and providing a summary of explanation.

Right To Request A Restriction Of Your PHI: You may ask us not to use or disclose any part of your PHI for the purposes of your obtaining treatment, our payment for your treatment or healthcare operations as described above. However, it will be the Fund’s policy not to agree to such requests because in order to deliver the benefits to which you are entitled from the Fund, we must use or disclose certain PHI.

You may also request that we not disclose particular portions of your PHI to family members, friends or other personal representatives who may be involved in your care or for notification purposes as described above. We are not required to agree to a restriction that you may request. However, if we do agree to the request, we will not use or disclose your PHI in violation of that restriction, unless it is needed to provide emergency treatment or we terminate the restriction with or without your agreement. The restriction will continue to apply to PHI created or received prior to our notice to you of our termination of the restriction.

To request a restriction you must write to our Privacy Officer at the address below indicating what information you want to restrict, whether you want to limit use, disclosure or both, and to whom you want the restrictions to apply.

Right To Amend Your PHI: If you believe that PHI that we have about you is incorrect or incomplete, you may request it to be amended. Your request must be made in writing and submitted to our Privacy Officer. In addition, you must provide a reason that supports your request.

We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that:

Was not created by us, unless the person or entity that created the information is no longer available to make the amendment;
Is not part of the medical information kept by the Fund;
Is not part of the information which you would be permitted to inspect and copy;
Is accurate and complete.

If we deny your request for amendment, you have the right to file a written statement of disagreement with us or you can request us to include your request for amendment along with the information sought to be amended if and when we disclose it in the future. We may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal.

Right to an Accounting of Disclosures: You have the right to request an accounting or list of disclosures made by the Fund or its Business Associates of your PHI. We are required to comply with your request except with respect to disclosures:

Made to carry out treatment, payment or health care operations;
Made to you regarding your own PHI;
Pursuant to your written authorization;
To a person involved in your care or for other similar notification purposes;
For national security or intelligence purposes;
To correctional institutions or law enforcement officials;
Included as part of a limited Data Set;
That is merely incidental to another permissible use or disclosure.

To request an accounting of disclosures, you must submit your request ion writing to our Privacy Officer. You have the right to receive an accounting of disclosures of PHI made within six years (or less) of the date on which the accounting is requested, but not prior to April 14, 2003. Your request should indicate the form in which you want the list (e.g., paper or electronic). The first request within a 12 month period will be free. For additional requests within the 12 month period, we will charge you for the costs of providing the accounting. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.

Right to Obtain a Paper Copy of This Notice: You may request a paper copy of this Notice at any time, even if you have previously agreed to accept this notice electronically.

COMPLAINTS

If you believe that your privacy rights have been violated, you may file a complaint with us or to the Secretary of Health and Human Services. To file a complaint with us, you must notify our Privacy Officer at the address below of your complaint in writing. We will not retaliate against you for filing a complaint.

FOR QUESTIONS OR REQUESTS

If you have any questions regarding this Notice of Privacy Practices or would like to submit a written request as described above, please contact:

Privacy Officer
Local 805 Welfare Fund
44-61 11th Street, 3rd Floor
Long Island City, NY 11101
718-609-6401