United Service Workers Union 138-50 Queens Boulevard
Briarwood, NY 11435
Tel: (718) 658-4848
Fax: (718) 523-5722
This notice describes how medical information about you may be used by the United Welfare Fund - Welfare Division ("United Welfare Plan"), United Welfare Fund Self-insured Dental Plan ("Dental Plan") (Collectively "The Plan" or "The Fund"). It also describes how you can get access to this information. Please review it carefully.
Notice of Privacy Practices
THIS NOTICE IS IN EFFECT AS OF APRIL 14, 2003
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED BY THE UNITED WELFARE FUND—WELFARE DIVISION (“UNITED WELFARE PLAN”), UNITED WELFARE FUND SELF-INSURED DENTAL PLAN (“DENTAL PLAN”) (COLLECTIVELY “THE PLAN” OR “THE FUND”). IT ALSO DESCRIBES HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. We are required by law to maintain the privacy of your personal health information and to provide you with this notice of our privacy practices and legal duties. We are required to abide by the terms of this notice.
If you have any questions about this notice, please contact Kevin Coughlan, Fund Administrator and Privacy Officer at 138-50 Queens Boulevard, Briarwood, New York 11435, (718) 658.4848, extension 287.
We reserve the right to change the terms of this notice and to make any new provisions effective as to all of the personal health information that we maintain about you. If we revise this notice, we will post a copy of the revised notice on the Plan website or otherwise notify you of the change.
Our Pledge Regarding Medical Information
We understand that medical information about you and your health is personal. We are committed to protecting medical information about you. This notice applies to all of the medical records we maintain. Your personal doctor or healthcare provider may have different policies or notices regarding the doctor’s use and disclosure of your medical information created in the doctor’s office or clinic.
This notice will tell you about the ways in which we may use and disclose medical information about you. It also describes our obligations and your rights regarding the use and disclosure of medical information.
We do not sell information about you. We do not share information with anyone else for marketing purposes. We only use your health information to administer the Plan.
We are required by law to:
How We May Use and Disclose Medical Information About You
The following categories describe different ways that we may use and disclose medical information. For each category of uses or disclosures we will explain what we mean and present some examples. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information will fall within one of the categories.
For Treatment (as described in applicable regulations). We may use or disclose medical information about you without your permission to facilitate medical treatment or services by providers. We may disclose medical information about you to providers, including doctors, nurses, technicians, medical students, or other hospital personnel who are involved in taking care of you. For example, we might disclose information about your prior prescriptions to a pharmacist to determine if a pending prescription is contra-indicative with prior prescriptions.
For Payment (as described in applicable regulations). We may use or disclose medical information about you without your permission to determine eligibility for Plan benefits, to determine coverage, to reimburse you for the provision of health care, to facilitate payment for the treatment and services you receive from health care providers, to determine benefit responsibility under the Plan, or to coordinate Plan coverage. For example, we may tell your health care provider about your medical history to determine whether a particular treatment is experimental, investigational, or medically necessary or to determine whether the Plan will cover the treatment. We may also share medical information with a utilization review or precertification service provider. Likewise, we may share medical information with another entity to assist with the adjudication or subrogation of health claims or to another health plan to coordinate benefit payments.
For Health Care Operations (as described in applicable regulations). We may use or disclose medical information about you without your permission for other Plan operations. These uses and disclosures are necessary to run the Plan. For example, we may use medical information in connection with: conduction quality assessment and improvement activities; underwriting, premium rating, and other activities relating to Plan coverage; submitting claims for stop-loss (or excess loss) coverage; conducting or arranging for medical review, legal services, audit services, and fraud and abuse detection programs; business planning and development such as cost management; and business management and general Plan administrative activities.
As Required By Law. We will disclose medical information about you when required to do so by federal, state or local law. For example, we may disclose medical information when required by a court order in a litigation such as a malpractice action.
To Avert A Serious Threat to Health or Safety. We may use and disclose medical information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure, however, would only be to someone able to prevent the threat. For example, we may disclose medical information about you in a proceeding regarding the licensure of a physician.
Disclosure to Third Parties. Information may be disclosed to other entities that provide business services to us related to our transactions with you, such as plan administration, claims processing, audit services, or administration services. For example, information may be disclosed to a third party that assists in the administration of the Plan and needs access to the information. Other examples are business agents, accountants, lawyers, consultants, or employees of the United Service Workers (“USW” or “the Union”) to the extent their services to or on behalf of the Fund necessitates the use of medical information about you. Before we disclose your information, these entities must agree to the privacy of your information.
We may also share information as part of an organized health care arrangement (“OCHA”) for the joint health care activities of the OCHA. For example, we may share information with our health insurance issuers or HMO’s or the health care providers in our network as necessary to carry out treatment, payment, or health care operations among those entities.
Organ and Tissue Donation. If you are an organ donor, we may release medical information to organizations that handle organ procurement or organ, eye or tissue transplantation or to an organ donation bank, as necessary to facilitate organ or tissue donation and transplantation.
Military and Veterans. If you are a member of the armed forces, we may release medical information about you as required by military command authorities. We may also release medical information about foreign military personnel to the appropriate foreign military authority.
Worker’s Compensation. We may release medical information about you as authorized and to the extent necessary to comply with laws relating to worker’s compensation or similar no-fault programs. These programs provide benefits for work related injuries or illness.
Public Health Risks. We may disclose medical information about you for public health activities. These activities generally include the following:
Health Oversight Activities. We may disclose medical in formation to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.
Lawsuits and Disputes. If you are involved in a lawsuit or dispute, we may disclose medical information about you in response to a court or administrative order. We may also disclose medical information about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or obtain an order protecting the information requested.
Law Enforcement. We may release medical information if asked to do so by a law enforcement official:
Coroners, Medical Examiners and Funeral Directors. We may release medicalinformation to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also release medical information about participants in the Fund to funeral directors as necessary to carry out their duties.
National Security and Intelligence Activities. We may release medical information about you to authorized federal officials for intelligence, counterintelligence, and any other national security activities authorized by law.
Inmates. If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release medical information about you to the correctional institution or law enforcement official. This release would be necessary for (1) the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) for the safety and security of the correctional institution.
For Any Purposes To Which You Have Not Objected. In certain limited circumstances, we may use or disclose your protected health information after we have given you an opportunity to object and you have not objected. For example, if you do not object, we may use limited information about you to maintain an office directory, to notify family members or any other person identified by you regarding issues directly related to such person’s involvement with your care or payment for that care, or in emergency circumstances.
Your Rights Regarding Medical Information About You
You have the following rights regarding medical information we maintain about you:
Right to Inspect and Copy. You have the right to inspect and copy medical information that may be used to make decisions about your Plan benefits. To inspect and copy medical information that may be used to make decisions about you, you must submit your request in writing to Kevin Coughlan, Fund Administrator and Privacy Officer. If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other supplies associated with your request.
We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to medical information, you may request that the denial be reviewed.
Right to Amend. If you feel that medical information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by or for the Plan.
To request an amendment, your request must be made in writing and submitted to Kevin Coughlan, Fund Administrator. 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:
Right to an Accounting of Disclosures. You have the right to request an “accounting of disclosures.” This right does not include routine disclosures such as those made to carry out treatment, payment, or health care operations; disclosures to you of medical information about you; disclosures made pursuant to your written authorizations; disclosures that are merely incidental to another permissible use or disclosure; or disclosures that are part of a limited data set. These exemptions from the accounting requirement apply to the Plan and any business associate of the Plan.
To request this list or accounting of disclosures, you must submit your request in writing to Kevin Coughlan, Fund Administrator and Privacy Officer. Your request must state a time period which may not be longer than six years and may not include dates before April, 2003. Your request should indicate in what form you want the list (for example, paper or electronic). The first list you request within a 12 month period will be free. For additional lists during a 12 month period, we may charge you for the costs of providing the list. 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. We may deny your request for an accounting for any subsequent disclosures of your medical information by others that receive the information from us or our business associates.
Right to Request Restrictions. You have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment, payment or health care operations. You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or a friend. For example, you could ask that we not disclose information about a surgery you had.
We are not required to agree to your request.
To request restrictions, you must make your request in writing to Kevin Coughlan, Fund Administrator and Privacy Officer. At your request, you must tell us: (1) what information you want to limit; (2) whether you want to limit our use, disclosure or both; and (3) to whom you want the limits to apply, for example, disclosures to your spouse.
Right to Request Confidential Communications. You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail.
To request confidential communications, you must make your request in writing to Kevin Coughlan, Fund Administrator and Privacy Officer. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.
Right to a Paper Copy of This Notice. You have a right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice.
You may obtain a copy of this notice at our website, http://www.uswu.org.
To obtain a paper copy of this notice, direct your request to Kevin Coughlan, Fund Administrator and Privacy Officer.
Changes to This Notice
We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for medical information we already have about you as well as any information we receive in the future. We will post a copy of the current notice on the Plan website. The notice will contain on the first page, in the top right-hand corner, the effective date.
If you believe your privacy rights have been violated, you may file a complaint with the Plan or with the Secretary of the Department of Health and Human Services. To file a complaint with the Plan, contact Kevin Coughlan, Fund Administrator and Privacy Officer, at (718) 658.4848 extension 1208. All complaints must be submitted in writing.
You will not be penalized for filing a complaint.
Other Uses of Medical Information
Other uses and disclosures of medical information not covered by this notice or the laws that apply to us will be made only with your written permission. If you provide us permission to use or disclose medical information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose medical information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provided to you.
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