NOTICE OF PRIVACY PRACTICES OF THE MICHIGAN CONFERENCE OF TEAMSTERS WELFARE FUND
- review and auditing, including compliance reviews, medical reviews, legal services and compliance programs;
- business planning and development including cost management and planning related analyses and formulary development;
- business management and general administrative activities of the Fund, including member services and resolution of internal grievances, and
- certain marketing activities.
For example, the Fund may use your health information to conduct case management, quality improvement, disease management, utilization review, and provider credentialing activities or to engage in member service and grievance resolution activities.
For Treatment Alternatives. The Fund may use or disclose your health information to tell you about or recommend possible treatment options or alternatives that may be of interest to you.
For Distribution of Health Related Benefits and Services. The Fund may use or disclose your health information to provide to you information on health related benefits and services that may be of interest to you.
For Disclosure to Plan Sponsor. The Fund may disclose your health information to the plan sponsor, the Trustees of the Michigan Conference of Teamsters Welfare Fund, for plan administration functions.
Where Required or Permitted by Law. The Fund also may use or disclose your health information where required or permitted by law. Federal law, under the Health Insurance Portability and Accountability Act of 1996 generally permits health plans to use or disclose health information for the following purposes: where required by law; for public health activities; to report child or domestic abuse; for governmental oversight activities; pursuant to judicial or administrative proceedings; for certain law enforcement purposes; for a coroner, medical examiner, or funeral director to obtain information about a deceased individual; for organ, eye, or tissue donation purposes; for certain government-approved research activities; to avert a serious threat to an individual’s or the public’s health or safety; for certain government functions, such as related to military service or national security; or to comply with Workers’ Compensation laws.
AUTHORIZATION TO USE OR DISCLOSE HEALTH INFORMATION
Other than as stated above, the Fund will not disclose your health information other than with your written authorization. If you authorize the Fund to use or disclose your health information, you may revoke that authorization in writing at any time.
YOUR RIGHTS WITH RESPECT TO YOUR HEALTH INFORMATION
You have the following rights regarding your health information that the Fund maintains:
Right to Request Restrictions. You have the right to request restrictions on certain uses and disclosures of your health information. You have the right to request a limit on the Fund’s disclosure of your health information to someone involved in the payment of your care. However, the Fund is not required to agree to your request. If you wish to make a request for restrictions, please contact the Fund’s Privacy Officer at (313) 964-2400.
Right to Receive Confidential Communications. You have the right to request that the Fund communicate with you in a certain way if you feel the disclosure of your health information could endanger you. For example, you may ask that the 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 and mail to: Privacy Officer, Michigan Conference of Teamsters Welfare Fund, 2700 Trumbull Avenue, Detroit, MI 48216. The Fund will attempt to honor your reasonable requests for confidential communications.
Right to Inspect and Copy Your Health Information. You have the right to inspect and copy your health information. A request to inspect and copy records containing your health information must be made in writing and mailed to: Privacy Officer, Michigan Conference of Teamsters Welfare Fund, 2700 Trumbull Avenue, Detroit, MI 48216. If you request a copy of your health information, the Fund may charge a reasonable fee for copying, assembly and postage, if applicable, associated with your request.
Right to Amend Your Health Information. You have the right to request an amendment to your health information records that you believe are inaccurate or incomplete. The request will be considered as long as the information is maintained by the Fund. A request for an amendment of records must be made in writing and mailed to: Privacy Officer, Michigan Conference of Teamsters Welfare Fund, 2700 Trumbull Avenue, Detroit, MI 48216. The Fund may deny the request if you do not state why you believe your records to be inaccurate or incomplete. The request also may be denied if your health information records were not created by the Fund, if the health information you are requesting to amend is not part of the Fund’s records, if the health information you wish to amend includes information you are not permitted to change, or if the Fund determines the records containing your health information are accurate and complete.
Right to an Accounting. You have the right to obtain a list of disclosures of your health information made by the Fund for any reason other than for treatment, payment or health care operations, unless you have authorized the disclosure. The request must be made in writing and mailed to: Privacy Officer, Michigan Conference of Teamsters Welfare Fund, 2700 Trumbull Avenue, Detroit, MI 48216. The request should specify the time period for which you are requesting the information, but may not start earlier than April 14, 2003. The right to an accounting does not extend beyond six (6) years back from the date of your request. The Fund will provide the first accounting you request during any 12-month period without charge. Subsequent accounting requests may be subject to a reasonable cost based fee. The Fund will inform you in advance of the fee, if applicable.
Right to a Paper Copy of this Notice. You have a right to obtain and receive a paper copy of this Notice at any time, even if you have received this Notice previously or agreed to receive this Notice electronically. To obtain a paper copy, please contact the Privacy Officer at (313) 964-2400. You also may obtain a copy of the current version of the Fund’s Notice at its Web site, www.mctwf.org.
DUTIES OF THE FUND
The Fund is required by law to maintain the privacy of your health information as set forth in this Notice and to provide to you this Notice of its duties and privacy practices. The Fund is required to abide by the terms of this Notice, which may be amended from time to time. The Fund reserves the right to change the terms of this Notice by providing you with a copy of a revised Notice within sixty (60) days of the change and by making the new Notice provisions effective for all health information that it maintains. If the Fund changes its policies and procedures, the Fund will revise the Notice and will provide a copy of the revised Notice to you within 60 days of the change. You have the right to express complaints to the Fund and to the Secretary of the Department of Health and Human Services if you believe that your privacy rights have been violated. Any complaints to the Fund should be made in writing and mailed to: Privacy Officer, Michigan Conference of Teamsters Welfare Fund, 2700 Trumbull Avenue, Detroit, MI 48216. The 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.
TO CONTACT THE FUND WITH QUESTIONS
Please submit your written questions regarding your privacy rights to: Correspondence Department, Michigan Conference of Teamsters Welfare Fund, 2700 Trumbull Avenue, Detroit, MI 48216, or direct your calls to the Fund’s Member Services Department at (313) 964-2400.
This Notice is effective April 14, 2003.