NOTICE
OF PRIVACY PRACTICES
Bricklayers and Allied Crafts, Local No. 74 of DuPage County
,
Illinois
, a/k/a Masons’ and Plasterers’ Welfare Fund
(a/k/a Bricklayers & Allied Craftsmen Local 74 Welfare Fund)
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.
The Bricklayers and Allied Crafts, Local No. 74 of DuPage
County, Illinois, a/k/a Masons’ and Plasterers’ Welfare Fund (a/k/a Bricklayers & Allied Craftsmen Local 74 Welfare Fund)
(“Bricklayers
Local 74 Welfare Fund”) is required by law to take reasonable steps
to ensure the privacy of personally identifiable health information
(“protected health information”) and to inform you about:
·
The Bricklayers Local 74 Welfare Fund’s uses and
disclosures of protected health information;
·
Your rights with respect to protected health information;
·
The Bricklayers Local 74 Welfare Fund’s duties regarding
protected health information and related matters;
·
Your right to complain to the Bricklayers Local 74 Welfare
Fund and to the Secretary of the Department of Health and Human Services if
you believe that your privacy rights have been violated;
·
The person to contact regarding issues relating to your
privacy rights including complaints and questions regarding this Notice;
·
The Effective Date of this Notice.
USE AND DISCLOSURE OF
PROTECTED HEALTH INFORMATION
The Bricklayers Local 74 Welfare Fund may use or disclose protected
health information for certain purposes. Protected
health information generally includes all individually identifiable health
information transmitted or maintained by the Bricklayers Local 74 Welfare Fund
regardless of the form of this information, including oral, written and
electronic information. Protected
health information does not include “de-identified” information, which 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 an individual. The
purposes for which use and disclosure of protected health information can be
made are (1) for disclosure to you; (2) for carrying out treatment, payment
and health care operations; (3) for disclosure to the plan sponsor, the Board
of Trustees of the Bricklayers Local 74 Welfare Fund, for the purposes of
administering the Plan and for other functions specifically authorized under
the Department of Health and Human Service Regulations Regarding Privacy of
Individually Identifiable Health Information; (4) for particular purposes for
which use or disclosure is required or permitted under the Department of
Health and Human Service regulations regarding Privacy of Individually
Identifiable Health Information without authorization or opportunity to agree
or disagree with disclosure; (5) for disclosure to family members, other
relatives and close personal friends of information relevant to your care or
for their notification, following, if practicable, provision of opportunity
for you to agree or disagree with the disclosure; and (6) for other purposes
following your execution of written authorization for use and disclosure.
These purposes are described more fully below.
As also set forth below, with certain specific exceptions, the
Bricklayers Local 74 Welfare Fund will only disclose the “minimum
necessary” amount of protected health information.
1.
Disclosure to You.
The
Bricklayers Local 74 Welfare Fund may disclose protected health information to
you. Procedures for you to
obtain this information are set forth in the section concerning your rights
with respect to your protected health information.
2.
Use and Disclosure to Carry
Out Treatment, Payment or Health Care Operations.
The
Bricklayers Local 74 Welfare Fund may use or disclose protected health
information for purposes of treatment, payment or health care operations.
This can include disclosure to the plan sponsor, the Board of Trustees
of the Bricklayers Local 74 Welfare Fund, as discussed in Section 3, below.
a.
Treatment
The
Bricklayers Local 74 Welfare Fund may use or disclose protected health
information for the purpose of treatment.
“Treatment” is the provision, coordination or management of health
care and related services. It also
includes but is not limited to consultations and referrals between one or more
providers.
For
example, the Bricklayers Local 74 Welfare Fund may disclose to a treating
cardiac surgeon the name of a treating cardiologist so that the cardiac
surgeon may ask for diagnosis records from the treating cardiologist.
b.
Payment
The Bricklayers Local 74 Welfare Fund may use or disclose your
protected health information for the purpose of “payment.” “Payment”
includes but is not limited to actions regarding coverage determinations and
payment, including billing, claims management and determination, subrogation,
plan reimbursement, reviews for medical necessity and appropriateness of care,
utilization review and preauthorization.
For example, the Bricklayers Local 74 Welfare Fund may provide
information regarding your coverage or health care treatment to another health
plan under which you are covered to coordinate payment of benefits.
c.
Health Care Operations
The
Bricklayers Local 74 Welfare Fund may use or disclose protected health
information for the purpose of conducting its “health care operations.”
“Health care operations” include such activities as:
·
Quality
assessment and improvement activities.
·
Activities
designed to improve health or reduce health care costs.
·
Clinical
guideline and protocol development, case management and care coordination.
·
Contacting
health care providers and participants with information about treatment
alternatives and other related functions.
·
Health care
professional competence or qualifications review and performance evaluation.
·
Accreditation,
certification, licensing or credentialing activities.
·
Underwriting,
premium rating or related functions to create, renew or replace health
insurance or health benefits.
·
Conducting or
arranging for medical reviews, legal services, compliance programs and
auditing functions, including fraud and abuse prevention.
·
Business
planning and development including cost management and planning related
analyses and formulary development.
·
Business
management and general administrative activities of the Bricklayers Local 74
Welfare Fund, including customer service and resolution of internal
grievances.
·
Certain
marketing activities.
For
example, the Bricklayers Local 74 Welfare Fund may use information about
claims to audit the accuracy of its claims processing function.
3.
Disclosure to the Plan Sponsor for Purposes of Plan Administration and
other Authorized Purposes.
The
Bricklayers Local 74 Welfare Fund may disclose your protected health
information to the plan sponsor, the Board of Trustees of the Bricklayers
Local 74 Welfare Fund, for the purposes of its administration of the Plan and
for other functions specifically authorized under the Department of Health and
Human Service Regulations Regarding Privacy of Individually Identifiable
Health Information. This
disclosure may be for purposes of the Bricklayers Local 74 Welfare Fund’s
treatment, payment and health care operations
a.
Disclosure to Board of Trustees of “Summary Health Information” for
Insurance Procurement and Amendment, Modification or Termination of the Plan.
The
Bricklayers Local 74 Welfare Fund may disclose to the Board of Trustees
“summary health information” (information which summarizes claims history,
claims expenses, or types of claims experienced by individuals for whom the
Trustees provide coverage under the Fund and from which aspects permitting
identification, other than a five-digit zip code, have been eliminated) in
order for the Board of Trustees to obtain premium bids from health plans for
providing health insurance coverage under the Bricklayers Local 74 Welfare
Fund or for the Board of Trustees to modify, amend or terminate the
Bricklayers Local 74 Welfare Fund.
b.
Disclosure to Board of Trustees of Enrollment-Related Information. In addition, the Bricklayers Local 74 Welfare Fund may
disclose to the Board of Trustees protected health information concerning
whether you participate in the Bricklayers Local 74 Welfare Fund or have
enrolled or disenrolled from a health insurance issuer or HMO, in the event
the Bricklayers Local 74 Welfare Fund were to ever have such options.
c.
Disclosure to Board of Trustees with Authorization. The
Bricklayers Local 74 Welfare Fund may disclose protected health information to
the Board of Trustees pursuant to an “authorization” discussed in Section
6 below.
d.
Disclosure to Board of Trustees for Purposes of Plan Administration. The
Bricklayers Local 74 Welfare Fund may disclose protected health information to
the Board of Trustees in order for the Trustees to carry out their
responsibilities to administer the Bricklayers Local 74 Welfare Fund.
For
example, the Bricklayers Local 74 Welfare Fund may disclose to the Board of
Trustees information relevant to the Board of Trustees’ responsibilities to
resolve an appeal regarding denial of a claim you might have for payment of
benefits regarding a particular type of medical services, such as radial
keratotomy, which is excluded from the Plan.
In
order to disclose protected health information to the Board of Trustees for
this purpose and for any other purpose other than those set forth in
Sub-Sections (a) through (c) above, the Board of Trustees must certify to the
Bricklayers Local 74 Welfare Fund that the plan documents have been amended to
restrict uses and disclosures of such information by the Board of Trustees to
those permitted by the Department of Health and Human Service Regulations
Regarding Privacy of Individually Identifiable Health Information.
4.
Use and Disclosure Required or Permitted Under HHS Regulations Without
Your Authorization or
Opportunity
to Disagree with Use or
Disclosure.
Under
the Department of Health and Human Service Regulations Regarding Privacy of
Individually Identifiable Health Information, the Bricklayers Local 74 Welfare
Fund is required or permitted to use or disclose protected health information
for certain purposes without either your authorization or opportunity to
disagree with the use or disclosure.
a.
Use or Disclosure Required by Law. The
Bricklayers Local 74 Welfare Fund may use or disclose protected health
information when it is required to do so by federal, state or local law.
b.
Use or Disclosure for Public Health Activities.
The Bricklayers Local 74 Welfare Fund may use or disclose
protected health information when permitted under the applicable regulations
for purposes of public health activities, including when necessary to report
product defects, to permit product recalls and to conduct post-marketing
surveillance. Protected health
information may also be used or disclosed if you have been exposed to a
communicable disease or are at risk of spreading a disease or condition, if
authorized by law.
c.
Use or Disclosure Regarding Victims of Abuse, Neglect or Domestic
Violence.
The Bricklayers Local 74 Welfare Fund may use or disclose protected
health information when authorized by law to report information about abuse,
neglect or domestic violence to public authorities if there exists a
reasonable belief that you may be a victim of abuse, neglect or domestic
violence. In such case, the
Bricklayers Local 74 Welfare Fund will promptly inform you that such a
disclosure has been or will be made unless that notice would cause a risk of
serious harm. For the purpose of
reporting child abuse or neglect, it is not necessary to inform the minor that
such a disclosure has been or will be made.
Disclosure may generally be made to the minor’s parents or other
representatives although there may be circumstances under federal or state law
when the parents or other representatives may not be given access to the
minor’s private health information.
d.
Use or Disclosure for Public Health Oversight Activities.
The Bricklayers Local 74 Welfare Fund may disclose protected health
information to a public health oversight agency for oversight activities
authorized by law. This
includes uses or disclosures in connection with audits, civil administrative
or criminal investigations, inspections, licensure or disciplinary action.
The Bricklayers Local 74 Welfare Fund, however, may not disclose your
protected 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.
e.
Use or Disclosure Related to Judicial and Administrative Proceedings.
As
permitted or required under state or federal law, the Bricklayers Local 74
Welfare Fund may disclose protected 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
Bricklayers Local 74 Welfare Fund makes reasonable efforts to either notify
you about the request, to obtain an order protecting your protected health
information or otherwise complies with the applicable terms of the HHS
Regulations.
f.
Use or Disclosure for Law Enforcement Purposes.
The Bricklayers Local 74 Welfare Fund may use or disclose protected
health information for law enforcement purposes which are specifically set
forth in the Department of Health and Human Service Regulations Regarding
Privacy of Individually Identifiable Health Information.
These situations include, but are not limited to cases in which the
Fund has a suspicion that your death may have resulted from criminal conduct
or the provision of certain limited information for purposes of identifying or
locating a suspect, fugitive, material witness or missing person.
g.
Use or Disclosure Concerning Persons who Have Died.
The Bricklayers Local 74 Welfare Fund may use or disclose protected
health information when required to be given to a coroner or medical examiner
for the purposes 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, to carry out duties with respect to a dead person or, if
necessary, in reasonable anticipation of the person’s death.
h.
Use or Disclosure for Cadaveric Organ, Eye or Tissue Donation Purposes.
The Bricklayers Local 74 Welfare Fund may use or disclose protected
health information in communications with organ procurement organizations or
other agencies engaged in the procurement, banking or transplantation of
cadaveric organs, eyes or issue for the purpose of facilitating donation and
transplantation.
i.
Use or Disclosure for Research Purposes.The
Bricklayers Local 74 Welfare Fund may use or disclose protected health
information for research purposes, to the extent permitted under the
Department of Health and Human Service Regulations Regarding Privacy of
Individually Identifiable Health Information.
j.
Use or Disclosure to Avert a Serious Threat to Health or Safety.
The Bricklayers Local 74 Welfare Fund may, consistent with applicable
law and ethical standards of conduct and within the limits permitted under the
Department of Health and Human Service Regulations Regarding Privacy of
Individually Identifiable Health Information use or disclose your protected
health information if the Bricklayers Local 74 Welfare Fund, in good faith,
believes that such disclosure is necessary to prevent or lessen a serious and
imminent threat to your health or safety or the health or safety of the
public.
k.
Use or Disclosure for Specialized Government Functions.
The Bricklayers Local 74 Welfare Fund may, to the extent permitted
under the Department of Health and Human Service Regulations Regarding Privacy
of Individually Identifiable Health Information, use or disclose your
protected health information to facilitate specialized governmental functions
related to the military and veterans, national security and intelligence
activities, protective services for the President and others, and correctional
institutions and inmates.
l.
Use or Disclosure for Workers’ Compensation.
The Bricklayers Local 74 Welfare Fund may disclose your protected
health information as authorized by and to the extent necessary to comply with
laws relating to workers’ compensation or other similar programs,
established by law, that provide benefits for work related injuries or illness
without regard to fault.
5.
Use and Disclosure Requiring, if Practicable,
Opportunity
for You to Agree or
Disagree.
The Bricklayers Local 74 Welfare Fund may also use or
disclose protected health information for the purposes listed in Sub-Sections
(a) and (b), if the conditions in Sub-Section (c) are followed:
a.
Disclosure to a Family Member, Relative, Friend or Other Identified
Person Involved in Your Health Care of Information Relevant to their
Involvement in Your Health Care or Payment for Care.
The Bricklayers Local 74 Welfare Fund may disclose to your
family member, other relative, your close personal friend or any other person
you identify, protected health information relevant to that person’s
involvement with your health care or with payment related to your health care.
Disclosure will be limited to the information which is directly
relevant to that person’s involvement with your health care.
b.
Disclosure to a Family Member, Your Personal Representative or Other
Person Responsible for Your Care of Your Location, General Condition or Death.
The
Bricklayers Local 74 Welfare Fund may disclose to a family member, your
personal representative or other person responsible for your care, information
concerning your location, general condition or death.
c.
Conditions on Disclosures set
Forth
in Sub-Section (a) and
(b).
If
you are present or otherwise available prior to a disclosure being made under
either Sub-Section (a) or (b) and you have the capacity to make health care
decisions, the Bricklayers Local 74 Welfare Fund will not make the disclosure
unless (1) your agreement to the disclosure is obtained, (2) you are given an
opportunity to object to the disclosure and do not, or (3) the Fund reasonably
infers from the circumstances, based on professional judgment, that you do not
object to the disclosure.
If
you are not present or otherwise available prior to a disclosure being made
under either Sub-Section (a) or (b) or if you cannot be given an opportunity
to agree or disagree with disclosure due to your incapacity or because of
emergency, the Bricklayers Local 74 Welfare Fund may, in the exercise of
professional judgment, determine whether disclosure is in your best interests
and, if so, disclose only the protected health information that is directly
relevant to the particular person’s involvement with your health care.
6.
Use and Disclosure Requiring Your Authorization.
Except
as stated in Sections 1 through 5, above, the Bricklayers Local 74 Welfare
Fund will not disclose protected health information other than with your
written authorization. You may
revoke your authorization in writing at any time subject to applicable law.
7.
Use and Disclosure of the “Minimum Necessary” Amount of Protected
Health Information.
When
using or disclosing protected health information or when requesting protected
health information from another covered entity, the Bricklayers Local 74
Welfare Fund 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:
·
Disclosure to
or requests by a health care provider for treatment;
·
Uses or
disclosures made to you;
·
Uses or
disclosures made pursuant to your written authorization, except for
authorizations requested by a covered entity, as described in the Regulations;
·
Disclosures
made to the Secretary of the U.S. Department of Health and Human Services;
·
Uses or
disclosure that are required by law; and
·
Uses or
disclosures that are required for the Bricklayers Local 74 Welfare Fund’s
compliance with legal regulations.
YOUR RIGHTS WITH
RESPECT TO PROTECTED HEALTH INFORMATION
You have the following rights regarding protected health information
that the Bricklayers Local 74 Welfare Fund maintains:
1.
Right to Request Restrictions on Use and Disclosure of Protected Health
Information.
You
may request the Bricklayers Local 74 Welfare Fund 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 Bricklayers Local 74 Welfare Fund is not required to agree
to your request. If you wish to
make a request for restrictions, please contact the Bricklayers Local 74
Welfare Fund, 415 E. Plaza Drive, Westmont, IL
60559, Telephone: (630)
734-0074, Fax: (630) 734-1870.
2.
Right to Receive Confidential Communications.
You
have the right to request that the Bricklayers Local 74 Welfare Fund
communicate with you in a certain way if you feel the disclosure of your
protected health information could endanger you.
For example, you may ask that the Bricklayers Local 74 Welfare Fund
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 Bricklayers Local 74 Welfare Fund, 415 E. Plaza Drive,
Westmont, IL 60559, Telephone:
(630) 734-0074, Fax: (630) 734-1870.
The Bricklayers Local 74 Welfare Fund will attempt to honor your
reasonable requests for confidential communications.
3.
Right to Inspect and Copy Your Protected Health Information.
You
have the right to inspect and copy your protected health information, which is
contained in a designated record set maintained by the Bricklayers Local 74
Welfare Fund with the exception of psychotherapy notes, information compiled
in reasonable anticipation of, or for use in, a civil, criminal, or
administrative action or proceeding or as otherwise precluded under the
Department of Health and Human Service Regulations Regarding Privacy of
Individually Identifiable Health Information.
A request to inspect and copy your protected health information must be
made in writing to Bricklayers Local 74 Welfare Fund, 415 E. Plaza Drive,
Westmont, IL 60559, Telephone:
(630) 734-0074, Fax: (630) 734-1870.
4.
Right to Amend Protected Health Information.
If
you wish to amend a record maintained by the Bricklayers Local 74 Welfare Fund
you may request that the Bricklayers Local 74 Welfare Fund amend the record.
The request may be made as long as the information is maintained by the
Bricklayers Local 74 Welfare Fund in a designated record set.
A request for an amendment of a record must be made in writing to
Bricklayers Local 74 Welfare Fund, 415 E. Plaza Drive, Westmont, IL
60559, Telephone: (630)
734-0074, Fax: (630) 734-1870. The Bricklayers Local 74 Welfare Fund may deny
the request if it does not include a reason to support the amendment.
The request also may be denied if the health information record was not
created by the Bricklayers Local 74 Welfare Fund, if the protected health
information you are requesting to amend is not part of the Bricklayers Local
74 Welfare Fund’s designated record set, if the protected health information
you wish to amend falls within an exception to the protected health
information you are permitted to inspect and copy under applicable law, or if
the Bricklayers Local 74 Welfare Fund determines the records containing your
protected health information are accurate and complete.
5.
Right to an Accounting of Disclosures of Protected Health Information.
You
have the right to request a list of disclosures of your protected health
information made by the Bricklayers Local 74 Welfare Fund except for
disclosures made (a) for purposes of treatment, payment and health care
operations, (b) for other purposes exempt from accounting of disclosures under
the Department of Health and Human Service Regulations Regarding Privacy of
Individually Identifiable Health Information, or (c) to a family member,
relative, personal representative, friend or other designated representative
for involvement in your health care, payment for your health care or
notification. The request must be
made in writing to Bricklayers Local 74 Welfare Fund, 415 E. Plaza Drive,
Westmont, IL 60559, Telephone:
(630) 734-0074, Fax: (630) 734-1870.
The request should specify the time period for which you are requesting
the information, but may not request information for a date earlier than
April 14, 2003
.
Accounting requests may not be made for periods of time going back more
than six (6) years. The
Bricklayers Local 74 Welfare Fund will provide the first accounting you
request during any twelve (12) month period without charge.
Subsequent accounting requests may be subject to a reasonable
cost-based fee. The Bricklayers
Local 74 Welfare Fund will inform you in advance of the fee, if applicable.
6.
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 Bricklayers Local 74 Welfare Fund, 415 E. Plaza
Drive, Westmont, IL 60559,
Telephone: (630) 734-0074, Fax:
(630) 734-1870.
DUTIES
OF THE BRICKLAYERS LOCAL 74 WELFARE FUND
The
Bricklayers Local 74 Welfare Fund is required by law to maintain the privacy
or your protected health information as set forth in this Notice and to
provide you this Notice of its duties and privacy practices.
The Bricklayers Local 74 Welfare Fund is required to abide by the terms
of this Notice, which may be amended from time to time.
The Bricklayers Local 74 Welfare Fund reserves the right to change the
terms of this Notice and to make the new Notice provisions effective for all
protected health information that it maintains.
If the Bricklayers Local 74 Welfare Fund changes its policies and
procedures, it will revise the Notice and will provide a copy of the revised
Notice to you within 60 days of the change.
YOUR RIGHT TO
COMPLAIN
You have the right to express complaints to the Bricklayers Local 74
Welfare Fund and to the Secretary of the United States Department of Health
and Human Services if you believe that your privacy rights have been violated.
Any complaints to the Bricklayers Local 74 Welfare Fund should be made
in writing to Bricklayers Local 74 Welfare Fund, 415 E. Plaza Drive, Westmont,
IL 60559, Telephone:
(630) 734-0074, Fax: (630) 734-1870.
The Bricklayers Local 74 Welfare Fund 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 Bricklayers Local 74 Welfare Fund has designated the following as
its contact person for all issues regarding your privacy rights, including
complaints and questions regarding this Notice:
Joette
Higgs, Administrative Manager
Bricklayers
Local No. 74 Welfare Fund
415 E. Plaza Drive
Westmont
,
IL
60559
Telephone:
(630) 734-0074
Fax:
(630) 734-1870
EFFECTIVE DATE
The Notice is effective
April 14, 2003
.
