Notice of Privacy Practices for UFCW 655 Welfare Fund

This Notice Describes How Medical Information About You May Be Used and Disclosed and How You Can Get Access To This Information. Review It Carefully.

This notice is intended to explain to you our practices related to the use and disclosure of your health information, and to inform you of your rights related to your health information.

We are required by law to:

  1. Maintain the privacy of your health information;
  2. Give you this notice of our legal duties and privacy practices with respect to health information about you; and
  3. Follow the terms of the notice that is currently in effect.

This notice is effective as of April 13, 2003.

How We May Use and Disclose Medical Information About You:

We may use your health information, as described in each category below, for treatment purposes, for payment purposes, and for our health care operations. We provide for each of these categories an example of how your health information might be used.

Treatment

We may use or disclose your health information to facilitate your health care treatment. For example, we might disclose information to your health care provider to assist them in making a determination on a course of treatment for you.

Payment

We may use and disclose health information about you for purposes related to payment. For example, we may use your health information to obtain premiums or to determine our responsibility for coverage under the plan. As another example, we may use your health information to coordinate benefits with another health plan.

Health Care Operations

We may use and disclose health information about you in order to carry-out the day to day health care operations of our health plan. For example, we may use health information in connection with:

  • Legal services;
  • audit services;
  • business planning and development;
  • and Business management of the Plan.

  1. Public Health Activities.
  2. For example, we may disclose information to a public health authority for the purpose of preventing or controlling disease.

  3. Reporting Abuse, Neglect or Domestic Violence.

    For example, circumstances may arise where we need to disclose to appropriate authorities suspected abuse or domestic violence.

  4. Health Oversight Activities.

    We may disclose health information to a government agency conducting an audit. For example, it may be necessary for us to disclose information pursuant to a Medicare audit.

  5. Judicial or Administrative Proceedings.

    For example, we may disclose information pursuant to a court order, subpoena, or a discovery request related to a trial proceeding.

  6. Law Enforcement Purposes.

    For example, it may be necessary for us to disclose information to law enforcement officials regarding the identification or location of suspects, fugitives, or missing persons.

  7. Medical Directors, Coroners, and Funeral Directors.

    In the event of your death, we may disclose your health information to medical directors, coroners, or funeral directors. For example, disclosure may be necessary for determining a cause of death.

  8. Organ and Tissue Donation.

    We may disclose your information to organizations handling organ and tissue donation.

  9. Disclosures to Avert a Serious Threat to Health or Safety.

    For example, we may disclose information to appropriate authorities in order to protect the safety of an individual.

  10. For Specialized Government Functions.

    We may disclose health information pursuant to certain governmental functions. For example: military or veteran activities; or national security activities.

  11. Workers’ Compensation.

    We may release information in accordance with applicable Workers’ Compensation laws.

  12. Disclosures to the Plan Sponsor.

    The Plan may disclose health information to the Trustees of the Plan in order to carry out plan administration functions.

All Other Uses or Disclosures

We may not use or disclose your health information for any other purpose other than described above without your specific written authorization. You may revoke any such authorization in writing at any time. However, any revocation is limited to the extent that the Plan has already taken action in reliance upon your authorization.

Your Rights Regarding Health Information

Federal law provides you with several rights regarding your health information:

  1. Right to Inspect and Copy Your Health Information.

    You have the right to inspect and copy the health information that we maintain about you. You must submit any request to inspect or copy your health information in writing. All such written requests should be forwarded to:

    United Food & Commercial Workers Local 655 Welfare Plan
    ATTENTION: Privacy Officer
    13537 Barrett Parkway Drive, Suite 100
    Manchester, MO 63021

    If you request a copy of your information, we may charge a reasonable fee for the costs of copying, mailing or other supplies associated with your request.

  2. Right to Amend Your Health Information.

    You have the right to request an amendment to your health information maintained by our Plan, for as long as the information is kept by our Plan. You may wish to request an amendment to your information if you feel that the information is inaccurate or incomplete.

    You must make any request for amendment in writing. Your request should be submitted to:

    United Food & Commercial Workers Local 655 Welfare Plan
    ATTENTION: Privacy Officer
    13537 Barrett Parkway Drive, Suite 100
    Manchester, MO 63021

    A request must state the reason you feel the amendment is necessary.

  3. Right to an Accounting of Disclosures.

    You have the right to receive an accounting of certain disclosures of your health information made by the Plan. This accounting does not include disclosures made pursuant to treatment, payment, healthcare operations, or your individual authorization.

    You must submit a request for an accounting of disclosures in writing to:

    United Food & Commercial Workers Local 655 Welfare Plan
    ATTENTION: Privacy Officer
    13537 Barrett Parkway Drive, Suite 100
    Manchester, MO 63021

    Your request should state the time period for which you would like an accounting, which cannot go beyond the six-years prior to the date of your request. You are not entitled to an accounting of disclosures made prior to April 14, 2003.

    You are entitled to one free accounting within any 12-month period. We may charge you a reasonable fee for any other accounting made within this same 12-month period. We will notify you of the cost involved and you may choose to withdraw or modify your request before any costs are incurred.

  4. Right to Request Restrictions.

    You have the right to request specific restrictions on our uses and disclosures of your health information. For example, you have the right to request that we not disclose any of your health information for treatment purposes. We do not have to agree to a requested restriction. Agreeing to a restriction is within our sole discretion.

  5. Right to Request Confidential Communications.

    You have the right to request that we communicate specific information to you in a certain manner or at a certain location, if you feel that the communication might otherwise place you in danger. For example, you may request that an explanation of benefits be sent to your work rather than to your home if you feel that this information may put you in danger if sent to your home.

    Any request for a confidential communication must be made in writing and be accompanied by a statement that the confidential communication is necessary to avoid your personal endangerment. All requests should be submitted to:

    United Food & Commercial Workers Local 655 Welfare Plan
    ATTENTION: Privacy Officer
    13537 Barrett Parkway Drive, Suite 100
    Manchester, MO 63021

  6. Right to a Paper Copy of This Notice.

    You have the right to receive a paper copy of this notice at any time. To request a paper copy of this notice, please contact:

    United Food & Commercial Workers Local 655 Welfare Plan
    ATTENTION: Privacy Officer
    13537 Barrett Parkway Drive, Suite 100
    Manchester, MO 63021

Revisions to This Notice

We reserve the right to change the terms of this notice. Any changes to this notice will be effective for health information that we maintain about you. Should we revise this notice, we will promptly provide you with a new Notice by mailing you a written copy of the new notice.

Complaints

If you believe your privacy rights have been violated, you have the right to 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:

United Food & Commercial Workers Local 655 Welfare Plan
ATTENTION: Privacy Officer
13537 Barrett Parkway Drive, Suite 100
Manchester, MO 63021

Your privacy rights will not be affected by filing a complaint. Further, you will not be retaliated against in any manner for filing a complaint.