CSEA Employee Benefit Fund Notice of Privacy Practices

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

OUR COMMITMENT TO YOUR PRIVACY

At the Employee Benefit Fund (EBF), we are dedicated to maintaining the privacy of your medical information. In our daily operations, we will create records regarding our members and the services we provide. Such records will include information about treatment and services you have received as well as the payment for those services. We may also receive non-public information such as name, date of birth, address and phone number. We do not give out any medical information about our current or former members except as permitted by law or to provide services to our members.

The EBF restricts access to information to those EBF employees who need to know such information in order to provide services. The EBF also maintains physical, electronic and procedural safeguards that comply with federal and state laws and regulations, including the HIPAA Privacy Rule, to guard your information.

We are required by law to maintain the confidentiality of medical information that identifies you. We are also required by law to provide you with this notice of our legal duties and our privacy practices concerning your medical information. By law, we must follow the terms of the notice of privacy practices that we have in effect at the time.

The EBF reserves the right to change this Notice of Privacy Practices as well as our privacy policies and procedures as required by business needs or changes in federal or state law. If there are significant changes to the privacy practices described in this Notice, a new Notice of Privacy Practices will be provided to our members by mail and by prominent posting on the EBF website, www.cseaebf.com.

If you have questions about any part of this Notice or, if you want more information about privacy practices at the EBF, please contact the CSEA EBF Privacy Officer at (800) 323-2732.

THE EFFECTIVE DATE OF THIS NOTICE IS MARCH 1, 2012.

USES AND DISCLOSURES OF YOUR HEALTH INFORMATION

The following categories describe ways in which we may use and disclose your medical information without your consent or authorization:

Treatment: We may disclose your medical information to a health care provider for your treatment.

Payment:We may use and disclose your medical information to pay claims for covered services or to determine whether EBF is responsible for payment of services rendered to you. For example, before paying a provider’s bill, EBF may use your medical information to determine whether the terms of your benefit plan cover the care you received.

Health Care Operations: The EBF may use and disclose your medical information to operate our business. For example, your medical information may be used to evaluate the quality of care you received from a provider or to conduct cost management and business planning activities for our organization.

Disclosures Required By Law: The EBF will use and disclose your medical information when we are required to do so by federal, state or local law.

Disclosures to You: EBF may disclose your medical information to you.

Disclosures to Individuals Involved with Your Care: Unless you notify EBF otherwise, EBF may disclose your medical information to your relative, friend or other person you identify, if the information relates to that person’s involvement with your care or payment for your care.

Disclosures to a Third Party: In order to protect the privacy of our members and ensure compliance with applicable state and federal laws and regulations, the EBF will not provide protected health information to any third party entity other than the member’s treating Dentist, Optometrist, Ophthalmologist or Business Associate of such a medical profession or as otherwise required by law.

Public Health Risks: Our organization may disclose your medical information to public health authorities that are authorized by law to collect information for a specific purpose. Some examples would be to prevent or control disease, injury or disability, to notify a person regarding potential exposure to a communicable disease or potential risk in spreading or contracting a disease or notifying individuals if a product or device has been recalled.

Health Oversight: Our organization may disclose your medical information to a health oversight agency for activities authorized by law. Oversight activities can include investigations, inspections, audits, surveys, licensure and disciplinary actions. They may also include civil, administrative and criminal procedures or actions as well as other activities necessary for the government to monitor programs, compliance with civil rights laws and the health care system in general. Legal Proceedings: We may disclose your medical information in response to a court order or subpoena.

Law Enforcement: The EBF may disclose your medical information for law enforcement proceedings such as identifying or locating a suspect, fugitive or material witness and for similar circumstances.

Serious Threats to Health and Safety: Our organization may use and disclose medical information to applicable persons or organizations that can help in reducing or preventing a serious threat to your health and safety or that of another individual or the public.

Military: If you are a member of the U.S. Armed Forces or a foreign military force, EBF may use or disclose your medical information if the appropriate military authorities requires us to do so. National Security: The EBF may disclose your medical information to federal officials for intelligence and national security activities authorized by law.

Inmates: We may disclose your medical information to correctional institutions or law enforcement officials if you are an inmate in their custody. This may be necessary for the institution to provide health care services to you, for the safety and security of the institution, and/or to protect your health and safety or that of another individual.

Worker’s Compensation: The EBF may release your medical information to comply with workers’ compensation laws and similar programs providing benefits for work-related injuries or illnesses.

Uses and Disclosures of Medical Information with an Authorization: Unless otherwise authorized by law, the EBF may use or disclose your medical information under circumstances that are not described above only if you provide permission by a signed authorization. You may revoke your authorization, in writing, at any time, by sending notice of the revocation to: HIPAA Privacy Officer, CSEA EBF, One Lear Jet Lane, Suite One, Latham, NY 12110. If you revoke an authorization, the EBF will no longer use or disclose your medical information under the circumstances permitted by the authorization. However, your revocation will not be effective for information the EBF has already used or disclosed, relying on that authorization.

YOUR MEDICAL INFORMATION RIGHTS

You have the following rights associated with your medical information:

Confidential Communication Right: You have the right to request that our office communicate with you about your medical information in a particular manner (for example, by email) or at a certain location (for example, at a post office box). In order to request that type of confidential communication, you must write to: HIPAA Privacy Officer, CSEA EBF, One Lear Jet Lane, Suite One, Latham, NY 12110, specifying the requested method of contact, or location where you wish to be contacted. Our organization will accommodate reasonable requests. Restriction Right: You have the right to ask for restrictions on the EBF’s uses and disclosures of your medical information. You must make your request in writing to: HIPAA Privacy Officer, CSEA EBF, One Lear Jet Lane, Suite One, Latham, NY 12110. The EBF is not required to agree to your restriction requests.

Amendment Right: You have the right to ask us to correct your medical information or add missing information if you think there is a mistake. You must send us a request in writing to: HIPAA Privacy Officer, CSEA EBF, One Lear Jet Lane, Suite One, Latham, NY 12110. We will respond to you in writing. If your request is approved, we will make the change to your medical information and advise you that the change has been made. We will also notify others who need to know of the change. We may deny your request if your medical information is: a) correct and complete; b) not made by us; c) not allowed to be disclosed; or d) not part of our records.

Accounting of Disclosures Right: You have the right to request a list of certain disclosures of your medical information that have been made by the EBF. All requests must be made in writing to: HIPAA Privacy Officer, CSEA EBF, One Lear Jet Lane, Suite One, Latham, NY 12110 and state a time period which is not to exceed six years and cannot include dates prior to April 14, 2003. The first list you request within a 12 month period is free of charge but you may be charged for additional lists within a 12 month period. We will notify you of the costs involved with additional requests and you may withdraw your request before you incur any costs.

Right to File a Complaint: If you believe your privacy rights have been violated, you may file a complaint with our organization or with the Secretary of Health and Human Services. To file a complaint with us, write to: HIPAA Privacy Officer, CSEA EBF, One Lear Jet Lane, Suite One, Latham, NY 12110. You will not be penalized or retaliated against for filing a complaint.

Right to Inspect and Copy. You have the right, in most cases, to inspect and copy your medical information maintained by or for the EBF. You must make your request in writing to: HIPAA Privacy Officer, CSEA EBF, One Lear Jet Lane, Suite One, Latham, NY 12110.

Right to a Paper Copy of This Notice. You have the right to request a paper copy of this Notice, even if you have received this Notice electronically. You may make your request in writing to: HIPAA Privacy Officer, CSEA EBF, One Lear Jet Lane, Suite One, Latham, NY 12110.

NEW YORK LAW

In certain instances, New York law provides more stringent or extensive privacy protections than those applicable under the HIPAA Privacy Rule. In such instances, the EBF will adhere to applicable New York law as it relates to your medical information. For example, the EBF will not disclose or cause to be disclosed any HIV-related information except as authorized by you or your qualified representative.