Northwestern Region Employee Benefit Trust
(NOREBT)
Northwestern Region Employee Benefit Trust
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.
USE AND DISCLOSURE OF HEALTH INFORMATION
Northwestern Region Employee Benefit Trust (Trust) may use your health information, that is, information that constitutes protected health information as defined in the Privacy Rule of the Administrative Simplification provision of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), for purposes of making or obtaining payment for your care and conducting health care operations. Trust has established a policy to guard against unnecessary disclosure of your health information.
THE FOLLOWING IS A SUMMARY OF THE CIRCUMSTANCES UNDER WHICH AND PURPOSES FOR WHICH YOUR HEALTH INFORMATION MAY BE USED AND DISCLOSED:
To Make or Obtain Payment. Trust may use or disclose your health information to make payment to or collect payment from third parties, such as other health plans or providers, for the care you receive. For example, Trust may provide information regarding your coverage or health care treatment to other health plans to coordinate payment of benefits.
To Conduct Health Care Operations. Trust may use or disclose health information for its own operations to facilitate the administration of Trust and as necessary to provide coverage and services to all of Trusts participants. Health care operations includes 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, rating or related functions to create, renew or replace health insurance or health benefits.
Securing or placing reinsurance, stop-loss insurance or excess of loss insurance.
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 Trust, including customer service and resolution of internal grievances or appeals.
For example, Trust may use your health information to conduct case management, quality improvement and utilization review, and provider credentialing activities or to engage in customer service and grievance or appeal resolution activities.
For Treatment Alternatives. Trust may use and 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. Trust 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 the Plan Sponsor. Trust may disclose your health information to the plan sponsor for plan administration functions performed by the plan sponsor on behalf of Trust. In addition, Trust may provide summary health information to the plan sponsor so that the plan sponsor may solicit premium bids from health insurers or modify, amend or terminate the plan. Trust also may disclose to the plan sponsor information on whether you are participating in the health plan.
When Legally Required. Trust will disclose your health information when it is required to do so by any federal, state or local law.
To Conduct Health Oversight Activities. Trust may disclose your health information to a health oversight agency for authorized activities including audits, civil administrative or criminal investigations, inspections, licensure or disciplinary action. Trust, however, may not disclose your 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.
In Connection With Judicial and Administrative Proceedings. As permitted or required by state law, Trust may disclose your 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 Trust makes reasonable efforts to either notify you about the request or to obtain an order protecting your health information.
For Law Enforcement Purposes. As permitted or required by state law, Trust may disclose your health information to a law enforcement official for certain law enforcement purposes, including, but not limited to, if Trust has a suspicion that your death was the result of criminal conduct or in an emergency to report a crime.
In the Event of a Serious Threat to Health or Safety. Trust may, consistent with applicable law and ethical standards of conduct, disclose your health information if Trust, in good faith, believes that such disclosure is necessary to prevent or lessen a serious and imminent threat to your health or safety or to the health and safety of the public.
For Specified Government Functions. In certain circumstances, federal regulations require Trust to use or disclose your health information to facilitate specified government functions related to the military and veterans, national security and intelligence activities, protective services for the president and others, and correctional institutions and inmates.
For Worker's Compensation. Trust may release your health information to the extent necessary to comply with laws related to worker's compensation or similar programs.
Other than as stated above, Trust will not disclose your health information other
than with your written authorization. If you authorize Trust to use or disclose your health information, you may revoke that authorization in writing at any time.
Pennsylvania laws also impose privacy standards under which the Trust is required to operate. These laws concern HIV or AIDS, mental health, substance abuse/chemical dependency, sexual abuse/sexual assault counseling records, etc. For example, under the Pennsylvania Confidentiality of HIV-Related Information Act, an insurer is not permitted to disclose an HIV-related positive test result to a subject. Also, if disclosure of HIV-related information is not permitted by the law, a specific authorization is required for disclosure.
YOUR RIGHTS WITH RESPECT TO YOUR HEALTH INFORMATION
You have the following rights regarding your health information that Trust maintains:
Right to Request Restrictions. You may request restrictions on certain uses and disclosures of your health information. You have the right to request a limit on Trusts disclosure of your health information to someone involved in the payment of your care. However, Trust is not required to agree to your request. If you wish to make a request for restrictions, please contact the Privacy Officer at (814) 734-8435.
Right to Receive Confidential Communications. You have the right to request that Trust 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 Trust 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 Privacy Officer, Northwest Tri-County Intermediate Unit, 252 Waterford Street, Edinboro, PA 16412 or fax to (814) 734-5806. Trust 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 to Privacy Officer, Northwest Tri-County Intermediate Unit, 252 Waterford Street, Edinboro, PA 16412 or fax to (814) 734-5806. If you request a copy of your health information, Trust may charge a reasonable fee for copying, assembling costs and postage, if applicable, associated with your request.
Right to Amend Your Health Information. If you believe that your health information records are inaccurate or incomplete, you may request that Trust amend the records. That request may be made as long as the information is maintained by Trust. A request for an amendment of records must be made in writing to Privacy Officer, Northwest Tri-County Intermediate Unit, 252 Waterford Street, Edinboro, PA 16412 or fax to (814) 734-5806. Trust may deny the request if it does not include a reason to support the amendment. The request also may be denied if your health information records were not created by Trust, if the health information you are requesting to amend is not part of Trusts records, if the health information you wish to amend falls within an exception to the health information you are permitted to inspect and copy, or if Trust determines the records containing your health information are accurate and complete.
Right to an Accounting. You have the right to request a list of certain disclosures of your health information that Trust is required to keep a record of under the Privacy Rule, such as disclosures for public purposes authorized by law or disclosures that are not in accordance with the Plan's privacy policies and applicable law. The request must be made in writing to Privacy Officer, Northwest Tri-County Intermediate Unit, 252 Waterford Street, Edinboro, PA 16412 or fax to (814) 734-5806. The request should specify the time period for which you are requesting the information, but may not start earlier than April 14, 2003. Accounting requests may not be made for periods of time going back more than six (6) years. Trust 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. Trust will inform you in advance of the fee, if applicable.
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 Privacy Officer, Northwest Tri-County Intermediate Unit, 252 Waterford Street, Edinboro, PA 16412 or fax to (814) 734-5806. You also may obtain a copy of the current version of Trusts Notice at its Web site, http://www.norebt.org.
DUTIES OF TRUST
Trust 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. Trust is required to abide by the terms of this Notice, which may be amended from time to time. Trust reserves the right to change the terms of this Notice and to make the new Notice provisions effective for all health information that it maintains. If Trust changes its policies and procedures, Trust 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 Trust 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 Trust should be made in writing to Privacy Officer, Northwest Tri-County Intermediate Unit, 252 Waterford Street, Edinboro, PA 16412. Trust 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
Trust has designated the Trust Operations Manager, as its contact person for all issues regarding patient privacy and your privacy rights. You may contact this person at Northwest Tri-County Intermediate Unit, 252 Waterford Street, Edinboro, PA 16412, (814) 734-8435.
EFFECTIVE DATE
This Notice is effective April 14, 2003.
IF YOU HAVE ANY QUESTIONS REGARDING THIS NOTICE, PLEASE CONTACT THE PRIVACY OFFICER.