THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION
ABOUT YOU MAY BE USED AND DISCLOSED
AND HOW YOU CAN GET ACCESS TO THIS INFORMATION

PLEASE REVIEW THIS CAREFULLY

We are providing this Notice from the American Federation of State, County and Municipal Employees District Council 47 Health & Welfare Fund (referred to in this Notice as the “Fund”) in order to inform you about the way that your health information may be used by the Fund. A federal law, the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), provides your health information with important protection.

The Fund is required by federal law to maintain the privacy of your protected health information (“PHI”). The Fund is also required by federal law to provide you with this description of the privacy policies and practices adopted by the Fund. The Fund must follow these policies and practices but, as permitted by law, the Fund reserves the right to amend or modify these privacy policies and practices. Changes in our policies and practices may be required by changes in federal and state laws and regulations. Regardless of the reason for the changes, we will provide you with notice of any material changes within sixty (60) days of the date the change is adopted. The effective date of this notice is April 14, 2003.

Under HIPAA, how can the Fund use my protected health information (“PHI”)? The Fund can use your PHI to facilitate your treatment, to make or obtain payment for your treatment and for health plan operations, including administration, oversight, and other legal purposes.

How may the Fund use my protected health information (“PHI”) with respect to payment for my treatment? The Fund may use your PHI for the broad range of actions needed to make sure that the Fund can make payment for the services you and your family receive. The Fund may use your PHI for making payment to providers for services or treatment you received, for making arrangements for payment through one of the networks of providers through which the Fund provides benefits to you, as well as for coordinating payment to providers through other health plans under the Fund’s coordination of benefit rules. For example, the Fund may provide information to your spouse’s health insurance carrier in order to coordinate benefits coverage when you both have coverage for a procedure.

Does HIPAA permit the Fund to use my protected health information (“PHI”) for other purposes? HIPAA provides that the Fund may use the PHI of the individuals the Fund covers for “health care operations.” This includes the broad range of actions required to assess the quality of the Fund’s plan of benefits as well as for its administration and operations. These activities include, but are not limited to, ensuring that participants or their beneficiaries are eligible for benefits prior to making payment; taking corrective action to recoup overpayments and assessing health plan performance; reviewing of the Fund’s plan of benefits and determining whether a reduction in costs is possible; continuing case management and coordination of care; commissioning and reviewing actuarial studies relating to the cost of benefits and management studies relating to the operation and administration of the plan; resolving internal grievances; and undertaking medical review, legal, and auditing functions. For example, the Fund may use PHI to determine the most cost-effective manner of providing vision benefits to its participants and beneficiaries.

May the Fund use my protected health information (“PHI”) for purposes besides payment and health care operations? Yes. HIPAA permits the Fund to use your PHI for a number of other purposes, including informing you of treatment alternatives or other health-related benefits that may be of interest to you.

My wife often calls to find out the status of my health claims and to get other information about me or my benefits. Can the Fund release information relating to payment of my claims to her? Unless you tell the Fund otherwise, the Fund will provide claims payment information to your spouse without requiring an authorization from you. If you do not wish the Fund to provide your spouse with this information, you must tell the Fund in writing that you do not wish the Fund to release claim payment information to your spouse. NOTE: If you wish the Fund to release other information to your spouse, please file an authorization form with the Fund office. Please call the Fund office for this form.

May I call the Fund to get information about my children’s health claims? The Fund will provide a minor child’s parent, guardian (or person standing in loco parentis with respect to the child) with payment information about the child’s claims. The Fund will carefully consider your written request for information other than claims payment information and will respond as permitted by these privacy policies and applicable state law. NOTE: If you child is not a minor, the Fund generally cannot provide you with the child’s PHI, even if the child is still covered under this Fund as your dependent.

Does HIPAA permit the Fund to disclose my protected health information (“PHI”) to my employer or insurers? Under HIPAA, the Fund generally cannot disclose your PHI to your employer without your written authorization. It is important to note, however, that HIPAA does permit that the Fund disclose your PHI without your authorization to workers’ compensation insurers, state administrators, or others involved in the workers’ compensation systems to the extent the disclosure is required by state or other law.

May the Fund release my protected health information (“PHI”) to the Fund’s plan sponsor? HIPAA does permit the Fund to disclose information to the “plan sponsor” for administrative functions. Here, the “plan sponsor” is the Fund’s Board of Trustees. The Fund may also provide summary health information to the plan sponsor so that the plan sponsor may solicit premium bids or modify, amend, or terminate the plan.

May the Fund release my protected health information (“PHI”) to law enforcement or other governmental entities? Your PHI may be disclosed to law enforcement agencies, without your authorization or permission, to support government audits and inspections, to facilitate law-enforcement investigations, and to comply with government-mandated reporting. Note, however, that the Fund may not disclose your PHI if you are the subject of an investigation that does not arise out of or is directly related to your receipt of health care or public benefits. In addition, the Fund may disclose your PHI in the course of a judicial or administrative proceeding if the Fund receives a court order, subpoena, discovery request or other lawful process. Before releasing this information, the Fund will make reasonable efforts either to notify you or to obtain an order protecting your PHI.

Would the Fund release my protected health information (“PHI”) if my health or safety or public health or safety would be jeopardized if it did not? If the Fund has a good faith belief that your health or safety or public health or safety would be jeopardized if it did not disclose the information, the Fund will do so, after consideration of appropriate legal and ethical standards.

Must the Fund have an authorization to release my protected health information (“PHI”)? Disclosure of your PHI or its use for any purpose other than those described above requires your written authorization. This means that if you want your friend, relative, or union representative to check on the status of a claim you submitted or to advise when or if payment will be made, you must sign an authorization form and submit it to the Fund Office. If you change your mind after authorizing a use or disclosure of your PHI, you may submit a written revocation of the authorization. However, your decision to revoke the authorization will not affect or undo any use or disclosure of information that occurred before you provided written notice to the Fund of your decision to revoke the authorization.

Do I have rights under the federal privacy standards? Your rights to information under HIPAA include:

the right to request restrictions on the use and disclosure of your PHI. The Fund will carefully consider, although is not required to honor, your request for restrictions;

the right to receive confidential communications concerning your medical conditions or treatment if your believe that disclosure of this information could endanger you (this means, for example, that you can make a written request that the Fund send information about your medical treatment to a post office box or an address different from your home address in order to ensure that your PHI remains confidential). The Fund will attempt to honor reasonable requests;

the right to inspect and copy your PHI. The Fund may charge a reasonable fee for copying, assembling and postage;

the right to amend or submit corrections to your PHI. If you believe that the information in your records are inaccurate or incomplete, you may submit a written request to correct these records. The Fund may deny your request if, for example, you do not include the reason you wish to correct your records or if the records were not created by the Fund.;

the right to receive an accounting of how and to whom your PHI has been disclosed if it was disclosed for reasons other than payment or health care operations. Your written request for information must be submitted to Fund and should state the period of time for which you are requesting an accounting;

the right to fille a complaint that your privacy rights have been violated to the Fund and to the Secretary of U.S. Department of Health & Human Services. Note: you will not be penalized or otherwise retaliated against for filing a complaint ;

the right to receive a printed copy of this notice. You can find this notice on the Fund’s website at www.dc47afscme.org

Complaints? Comments? Requests? The Fund has designated Robert McAllister, Fund Administrator, as the Privacy Officer. If you wish to request information to which you have a right to or to file a Complaint with the Fund or if you have any questions regarding this notice, you should address them to Mr. McAllister. Please note that the Fund can assess reasonable charges for copying assembling documents you request as well as for postage.