Notice of Privacy Practices

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Your Information - Your Rights - Our Responsibilities

This notice describes how medical information about you may be used and disclosed and how you can obtain access to this information. Please review it carefully.

Your Rights

When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.

Obtain a copy of health and claims records

You can request to see or request a copy of your health and claims records and other health information we have about you.
We will provide a copy or a summary of your health and claims records, usually within thirty (30) days of your request. We may charge a reasonable, cost-based fee.

Ask us to correct health and claims records

You can request that we correct your health and claims records if you think they are incorrect or incomplete.
We may say “no” to your request, but we will tell you why in writing within sixty (60) days.

Request confidential communications

You can request that we contact you in a specific way (for example, home or office phone) or to send mail to a different address.
We will consider all reasonable requests, and must say “yes” if you tell us you would be in danger if we do not.

Ask us to limit what we use or share

You can request that we not use or share certain health information for treatment, payment, or our operations.
We are not required to agree to your request, and we may say “no” if it would affect your care.

Obtain a list of those with whom we’ve shared information

You can request a list (accounting) of the times we have shared your health information for six years prior to the date of your request, who we shared it with, and why.
We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We will provide one (1) accounting per year for free, but will charge a reasonable, cost-based fee if you ask for another one within twelve (12) months.

Obtain a copy of this privacy notice

You can request a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.

Choose someone to act for you

If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.
We will make sure the person has this authority and can act for you before we take any action.

File a complaint if you feel your rights are violated

You can complain if you feel we have violated your rights by contacting:

PBA Funds Office
Office of the Funds Administrator
125 Broad Street – 11^th Floor New York, NY 10004
(212) 349-7560

You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/.
We will not retaliate against you for filing a complaint.

Your Choices

For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, please contact us. Tell us what you want us to do, and we will follow your instructions.

In these cases, you have both the right and choice to tell us to:

Share information with your family, close friends, or others involved in payment for your care.
Share information in a disaster relief situation.

If you are not able to communicate your preference, for example if you are unconscious, we may share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.

In these cases we never share your information unless you give us written permission

Marketing purposes
Sale of your information

Our Uses and Disclosures

How do we typically use or share your health information? We typically use or share your health information in the following ways:

Help manage the health care treatment you receive

We can use your health information and share it with professionals who are treating you.
Example: A dentist sends us information about your diagnosis and treatment plan so we can determine whether a particular dental service will be authorized.

Run our organization

We can use and disclose your information to run our organization and contact you when necessary.
We are not allowed to use genetic information to decide whether we will give you coverage and the price of that coverage. This does not apply to long term care plans.
Example: We use health information about you to develop better services for you.

Pay for your health services

We can use and disclose your health information as we pay for your health services.
Example: We share information about you with your spouse’s dental plan to coordinate payment for your dental work.

Administer your plan

We may disclose your health information to your health plan sponsor or benefit administrators for plan administration.
Example: We may provide information about you to a pharmacy benefit manager (PBM) so that you will be able to use your prescription drug benefits.

How else can we use or share your health information?

We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html .

Help with public health and safety issues

We can share health information about you for certain situations such as:

Preventing disease
Helping with product recalls
Reporting adverse reactions to medications
Reporting suspected abuse, neglect, or domestic violence
Preventing or reducing a serious threat to anyone’s health or safety

Do research

We can use or share your information for health research.

Comply with the law

We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we are complying with federal privacy law.

Respond to organ and tissue donation requests and work with a medical examiner or funeral director

We can share health information about you with organ procurement organizations.
We can share health information with a coroner, medical examiner, or funeral director when an individual dies.

Address workers’ compensation, law enforcement, and other government requests

We can use or share health information about you:

For workers’ compensation claims
For law enforcement purposes or with a law enforcement official
With health oversight agencies for activities authorized by law
For special government functions such as military, national security, and presidential protective services

Respond to lawsuits and legal actions

We can share health information about you in response to a court or administrative order, or in response to a subpoena.

Our Responsibilities

We are required by law to maintain the privacy and security of your protected health information.
We will inform you promptly if a breach occurs that may have compromised the privacy or security of your information.
We must follow the duties and privacy practices described in this notice and give you a copy of it.
We will not use or share your information other than as described here unless you consent in writing. If you consent, you may change your mind at any time. Inform us in writing if you change your mind.

For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html .

Changes to the Terms of this Notice

We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, on our web site, and we will mail a copy to you.

Who to Contact for Information

For more information about this notice or our privacy practices, please contact:

PBA Funds Office
Office of the Funds Administrator
125 Broad Street – 11^th Floor
New York, NY 10004

Effective Date of this Notice

The effective date of this notice is July, 1, 2014.