Unified Fire Authority
Officer . You must provide the reason ( s ) to support your request . The plans may deny your request if you ask to amend health information that was : accurate and complete , not created by the plans ; not part of the health information kept by or for the plans ; or not information that you would be permitted to inspect or copy .
Right to an Accounting of Disclosures . You have the right to request an “ accounting of disclosures .” This is a list of disclosures of your PHI that the plans have made to others , except for those necessary to carry out health care treatment , payment , or operations ; disclosures made to you ; disclosures made prior to this effective date at the end of this notice ; or in certain other situations . To request an accounting of disclosures , submit your request in writing to the Privacy Officer . Your request must state a time period , which may not be longer than six years prior to the date the account was requested .
Right to Request Restrictions . You have the right to request a restriction on the health information the plans use or disclose about you for treatment , payment , or health care operations . You also have the right to request a limit on the health information the plans disclose about you to someone who is involved in your care or the payment of your care , like a family member or friend . For example , you could ask that the plans not use or disclose information about a surgery you had . To request restrictions , make your request in writing to the Privacy Officer . You must advise us : 1 ) what information you want to limit ; 2 ) whether you want to limit the plans ’ use , disclosure , or both ; and 3 ) to whom you want the limit ( s ) to apply . Note : The plans are not required to agree to your request .
Right to Request Confidential Communications . You have the right to request that the plans communicate with you about health matters in a certain way or at a certain location . For example , you can ask that the plans send you explanation of benefits ( EOB ) forms about your benefit claims to a specified address . To request confidential communications , make your request in writing to the Privacy Officer . The plans will make every attempt to accommodate all reasonable requests . Your request must specify how or where you wish to be contacted .
A Note About Personal Representatives You may exercise your rights through a personal authorized representative . Your personal representative will be required to produce evidence of his or her authority to act on your behalf before that person will be given access to your PHI or allowed to take any action for you . Proof of such authority may take one of the following forms :
» A power of attorney for health care purposes , notarized by a notary public ;
» A court order of appointment of the person as the conservator or guardian of the individual ; or
» An individual who is the parent of a minor child . The plans retain discretion to deny access to your PHI to a personal representative to provide protection to those vulnerable people who depend on others to exercise their rights under these rules and who may be subject to abuse or neglect . This also applies to personal representatives of minors .
Change to this Notice The plans reserve the right to change this notice at any time and to make the revised or changed notice effective for health information the plans already have about you , as well as any information the plans receive in the future . The plans will post a copy of the current notice in the Employer ’ s office . All individuals covered under the Plan will receive a revised notice within 60 days of a material revision to the notice .
Notice of Breach of PHI You have a right to receive a notice when there is a breach of your unsecured PHI .
Complaints If you believe your privacy rights under this policy have been violated , you may file a written complaint with the Privacy Officer at the address listed below . Alternatively , you may file a complaint with the Secretary of the U . S . Department of Health and Human Services ( Hubert H . Humphrey Building , 200 Independence Avenue S . W ., Washington D . C . 20221 ), generally within 180 days of when the act or omission complained of occurred . Note : The plans , the Employer , and nay of its affiliates will not retaliate against you for filing a complaint .
Other Uses and Disclosures of Health Information A plan must obtain your written authorization to use or disclose psychotherapy notes , to use PHI for marketing purposes , or to sell PHI . An authorization for a use or disclosure of psychotherapy notes may only be combined with another authorization for a use and disclosure of psychotherapy notes .
Plans ( excluding long-term care plans ) are prohibited from using or disclosing PHI that is genetic information for underwriting purposes .
Other uses and disclosures of health information not covered by this notice or by the laws that apply to the plans will be made only with your written authorization . If you authorize the plans to use or disclose your PHI , you may revoke the authorization , in writing , at any time . If you authorize the plans to use or disclose your PHI , you may revoke the authorization , in writing , at any time . If you revoke your authorization , the plans will no longer use or disclose your PHI for the reasons covered by your written authorization ; however , the plans will not reverse any uses or disclosures already made .
Contact Information : If you have any questions about this notice , please contact the Privacy Officer at the Employer , Attention : Privacy Officer .
Updated and effective March 26 , 2013
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