UNION CONSTRUCTION WORKERS

HEALTH PLAN

P.O. Box 697                                                                                                   (419) 248-2401 Telephone

Toledo, Ohio    43697-0697                                                                             (419) 255-7136 Fax

  Toll Free 1-800-432-2924 OH, MI, IN, FL

  E-Mail:  UCWHP @NWOADM.COM

                        The Union Construction Workers Health Plan (Plan) treats your medical information as confidential.  However, the Plan must use and disclose medical information to others for payment and health care operations.  Medical information may be disclosed for the Plan’s purchase of insurance, or if there may be duplicate coverage requiring coordination of benefits.  Information may be disclosed to utilization review groups, and you and/or your medical providers may be contacted about treatment alternatives and health-related benefits.  Protected health information is sometimes disclosed to the Plan’s Trustees for Plan administration—for example, to act on claim appeals. 

                        The Plan is generally required to disclose health information to you, and when required by the Secretary of Health and Human Services to determine Plan compliance.  The Plan is also permitted and may be required to disclose information to public health agencies to satisfy certain reporting requirements, such as births and deaths, certain communicable diseases, child abuse, and other public health issues; to health oversight agencies, such as governmental auditors, a State Department of Health, and other agencies when required; to avert a serious threat to health or safety; to any individual when ordered by a court or other legal process to do so; to law enforcement officials when necessary for law enforcement purposes and required by law; to a coroner or medical examiner when necessary to enable them to perform their duties; to organ procurement organizations, to enable them to make suitability determinations; in cases of emergency; for workers’ compensation; to appropriate military authorities, if you are a member of the armed forces; to federal officials for lawful intelligence, counter-intelligence and other national security purposes; and incident to  a permitted or required use or disclosure.

                        For uses and disclosures not permitted or required (for example, use of psychotherapy notes), the Plan will seek your written authorization.  You may generally revoke that authorization.

Your Rights

For your private health information, you have certain rights:

• To request restrictions on certain uses and disclosures (but the Plan is not required to agree);

• To request communications by alternative means or at alternative locations stated in writing;

Your Rights (Continued)

• To generally inspect and copy such information (for a reasonable fee);

• To request amendment of information if you furnish your reason in writing;

• To receive an accounting of certain uses and disclosures other than those to carry out treatment, payment or health operations and certain other exceptions; and

• To receive a copy of this Privacy Policy upon request.

You may exercise the above rights by writing to the Privacy Contact at the address shown below.

Our Obligations

This Plan must:

• maintain the privacy of protected health information;

• furnish you with the Plan’s Privacy Policy, and act in accordance with this Policy; and

• notify you in writing of a change in this Privacy Policy, which change may be effective for protected health information received before the change.

                        The Plan cannot share health information with your Business Agent or Union Representative without a written Authorization Form from you.  If you desire to share your information with them (e.g., to help your Agent or Representative to assist you in pursuing a claim for benefits), contact the Plan Office and ask for an Authorization Form.

                        You should contact Cindy Hodnicki, Privacy Contact, at (419) 248-2401 for further information or to express any concerns regarding this Privacy Policy.  If the matter is not resolved or you believe your privacy rights have been violated, you should file a written complaint with the Privacy Contact, Union Construction Workers Health Plan, P. O. Box 697, 1600 Madison Avenue, Suite 300, Toledo, Ohio  43697-0697.  If the matter is not resolved within 30 days of your complaint, you should file a written complaint with the Board of Trustees, Union Construction Workers Health Plan, c/o Northwestern Ohio Administrators, Inc., P. O. Box 697, 1600 Madison Avenue, Suite 300, Toledo, Ohio  43697-0697.  You will not be retaliated against for any complaint.  You may also file a complaint with the Secretary of Health and Human Services.