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 Teamster Construction Industry Welfare Trust (the “Plan”) is required by law to take reasonable steps to protect the privacy and confidentiality of your health information. This Notice describes the Plan’s privacy practices. The term “Protected Health Information” (PHI), as used in this Notice, includes all individually identifiable health information transmitted or maintained by the Plan, regardless of form (oral, written, or electronic).

SECTION 1. USES AND DISCLOSURES OF PHI

Uses and disclosures to carry out treatment, payment and health care operations

The Plan and its business associates will use PHI to carry out treatment, payment and health care operations.

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 of your providers.

Payment includes but is not limited to actions to make coverage determinations and payment (including billing, claims management, subrogation, plan reimbursement, reviews for medical necessity and appropriateness of care and utilization review and preauthorizations). For example, the Plan may tell a doctor, dentist or vision care provider whether you are eligible for coverage or what percentage of the bill will be paid by the Plan.

Health care operations include but are not limited to quality assessment and improvement, reviewing competence or qualifications of health care professionals. It also includes case management, conducting or arranging for medical review, legal services and auditing functions including fraud and abuse compliance programs, business planning and development, business management and general administrative activities. For example, the Plan may use information about your claims to audit the accuracy of its claims processing functions or to resolve a claim appeal you file.

Uses and disclosures that require your written authorization
Except as otherwise indicated in this Notice, uses and disclosures will be made only with your written authorization, subject to your right to revoke such authorization.

Uses and disclosures that require that you be given an opportunity to agree or disagree prior to the use or release Disclosure of your PHI to family members, other relatives and your close personal friends is allowed if:

• The information is directly relevant to the family or friend’s involvement with your care or payment for that care; and
• You have either agreed to the disclosure or have been given an opportunity to object and have not objected.
  

Uses and disclosures for which authorization or opportunity to object is not required

• Use and disclosure of your PHI is allowed without your authorization or request under the following circumstances:
• When required by law, or for law enforcement purposes.
• When permitted for purposes of public health activities.
• To a public health oversight agency for oversight activities authorized by law. This includes uses or disclosures in civil, administrative or criminal investigations; inspections; licensure or disciplinary actions (for example, to investigate complaints against providers or to investigate Medicare or Medicaid fraud).
• When required for judicial or administrative proceedings.
• To a coroner or medical examiner for the purpose of identifying a deceased person, determining a cause of death or other duties as authorized by law.
• For research, subject to conditions.
• When authorized by and to the extent necessary to comply with workers’ compensation or other similar programs established by law.

SECTION 2. RIGHTS OF INDIVIDUALS

Right to Request Restrictions on PHI Uses and Disclosures

You may request the Plan to restrict uses and disclosures of your PHI 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 Plan is not required to agree to your request.

Right to Inspect and Copy PHI

You have a right to inspect and obtain a copy of your PHI contained in a designated record set, for as long as the Plan maintains the PHI.

Designated Record Set includes the enrollment, payment, billing, claims adjudication and case or medical management record systems maintained by or for a health plan; or other information used to make decisions about individuals. Information used for quality control or peer review analyses and not used to make decisions about individuals is not in the designated record set.

Right to Amend PHI

You have the right to request the Plan to amend your PHI or a record about you in a designated record set for as long as the PHI is maintained in the designated record set. You will be required to make request for amendment in writing and to provide a reason to support a request for amendment.

The Right to Receive an Accounting of PHI Disclosures

At your request, the Plan will also provide you with an accounting of disclosures by the Plan of your PHI during the six years prior to the date of your request. However, such accounting need not include PHI disclosures made:

1. to carry out treatment, payment or health care operations;
2. to individuals about their own PHI; or
3. prior to the effective date of this Notice.

The Right to Receive a Copy of This Notice Upon Request

To obtain a copy of this Notice, contact the person or office identified in section 5 below.

SECTION 3. THE PLAN’S DUTIES

The Plan is required by law to maintain the privacy of PHI, to provide individuals (participants and beneficiaries) with notice of its legal duties and privacy practices, and to comply with the terms of this Notice.

This Notice is effective beginning April 14, 2003, however, the Plan reserves the right to change its privacy practices and to apply the changes to any PHI received or maintained by the Plan prior to that date.

Minimum Necessary Standard

When using or disclosing PHI or when requesting PHI from another covered entity, the Plan will make reasonable efforts not to use, disclose or request more than the minimum amount of PHI 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:

• Disclosures to or requests by a health care provider for treatment;

• Uses or disclosures made to the individual;

• Disclosures made to the Secretary of the U.S. Department of Health and Human Services;

• Uses or disclosures that are required by law; and Uses or disclosures that are required for the Plan’s compliance with legal regulations.

In addition, the Plan may disclose your health information to the plan sponsor (which is the Board of Trustees) and to necessary advisors that assist the plan sponsor in performing plan administration functions, such as handling claim appeals. The Plan may also use or disclose “summary health information” to the plan sponsor for obtaining premium bids or modifying, amending or terminating the plan, which summarizes the claims history, claims expenses or type of claims experienced by individuals for whom a plan sponsor has provided health benefits; and from which identifying information has been deleted.

SECTION 4. YOUR RIGHT TO FILE A COMPLAINT WITH THE PLAN OR THE HHS SECRETARY

If you believe that your privacy rights have been violated, you may complain to the Plan in care of the person or office identified below.

Teamster Construction Industry Welfare Trust
Attn: Account Executive
2323 Eastlake Avenue East
Seattle, WA 98102
206-329-4900

You may also file a complaint with the U.S. Department of Health and Human Services, Region X, Office for Civil Rights, 2201 Sixth Ave, Ste 900, Seattle, WA 98121. The Plan will not retaliate against you for filing a complaint.

SECTION 5. WHOM TO CONTACT AT THE PLAN FOR MORE INFORMATION

If you have any questions regarding this notice or the subjects addressed in it, you may contact the following officer:

Northwest Administrators, Inc.
Attn: Privacy Officer
2323 Eastlake Avenue East
Seattle, WA 98102
206-329-4900