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Notice of Privacy Practices

Effective April 14, 2003

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY AND MAY NOT BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

IF YOU HAVE ANY QUESTIONS ABOUT THIS NOTICE, PLEASE CONTACT OUR PRIVACY OFFICER THROUGH THE HUMAN RESOURCES DEPARTMENT.

This notice is provided to you in accordance with federal privacy laws enacted to protect your medical information. This notice describes the privacy practices of health care carriers listed below and of the Cities plan, our legal duties, and your rights concerning your Protected Health Information. Protected Health Information (PHI) is information about you, including demographic information, that can reasonably be used to identify you and that relates to your past, present or future physical or mental health or condition, the provision of health care to you or the payment for that care.

Health care carriers and the Cities plan are required to follow the privacy practices that are described in this notice while it is in effect. However, health care carriers and the Cities plan reserve the right to change privacy practices and the terms of this notice at any time, provided that applicable law permits such changes. If health care carriers and/or the Cities plan make any substantive changes to our privacy practices, we will modify this notice and send you a new notice within 60 days of the change of the health care carrier and/or our practices.

You may request a copy of this notice at any time. For more information about our privacy practices or for additional copies of this notice; please contact the Human Resources Department.

This notice applies to the privacy practices of the health care carriers, third party administrators and our group health plan listed below:

NAME TYPE OF COVERAGE Definition
PERS Medical Third Party Administrator (TPA)
Delta Dental Dental The Cities plan
TLC Administrators Dental & Flexible Spending The Cities plan and TPA
Vision Service Plans Vision Health Care Carrier
MHN Employee Assistance Plan Health Care Carrier

Uses and disclosures of your medical information

Health care carriers, third party administrator and the Cities plan are permitted to use or disclose your PHI for the following purposes:

Treatment Health care carriers, third party administrators, and the Cities plan may use and disclose your PHI in order to assist your health care provider (doctors, hospitals, pharmacies, and others) in your diagnosis and treatment.

Payment Health care carriers, third party administrators, and the Cities plan use and disclose your PHI to pay claims from doctors, hospitals and other providers for services delivered to you that are covered by ythe Cities plan, to determine your eligibility for benefits, to coordinate benefits, to examine medical necessity, to obtain premiums, or to be reimbursed by another entity that may be responsible for payment.

Health Care Operations Health care carriers, third party administrators, and the Cities plan use and disclose your PHI in order to perform the Cities plan activities, such as quality assessment activities or administrative activities, including data management or customer service. In some cases, we may use or disclose your PHI for underwriting purposes, determining premiums, and the detection and investigation of fraud.

Other permitted or required disclosures

Health care carriers, third party administrators, and the Cities plan may also use or disclose your PHI in support of:

As Required By Law Health care carriers, third party administrators, and the Cities plan must disclose PHI about you when required to do so by law.

Plan Administration To the plan sponsor, employer or other organization that sponsors your group health plan, to permit the plan sponsor to perform plan administration functions, as described in ythe Cities plan documents.

Public Health Activities Health care carriers, third party administrators, and the Cities plan may disclose PHI to public health agencies for reasons such as prevention or controlling disease, injury or disability.

Business Associates To persons who provide services to us and assure health care carriers, third party administrators, and the Cities plan that they will comply with privacy regulations and our procedures on the use of PHI.

Law Enforcement Health care carriers, third party administrators, and the Cities plan may disclose PHI under limited circumstances to a law enforcement official in response to a warrant or similar process; to identify or locate a suspect; or to provide information about the victim of a crime.

Research Under certain circumstances, health care carriers, third party administrators, and the Cities plan may disclose PHI about you for research purposes, provided certain measures have been taken to protect your privacy.

Special Government Functions Health care carriers, third party administrators, and the Cities plan may disclose PHI as required by military authorities or to authorized federal officials for national security and intelligence activities.

Judicial and Administrative Proceedings Health care carriers, third party administrators, and the Cities plan may disclose PHI in response to a court or administrative order. Health care carriers, third party administrators, and the Cities plan may also disclose PHI about you in certain cases in response to a subpoena, discovery request or other lawful process.

Industry Regulation Health care carriers, third party administrators, and the Cities plan may disclose your PHI to state insurance departments, the U.S. Department of Labor and other government agencies, for activities authorized by law.

Workers’ Compensation Health care carriers, third party administrators, and the Cities plan may disclose PHI to the extent necessary to comply with state laws for workers’ compensation programs.

Coroners, Funeral Directors, Organ Donation Health care carriers, third party administrators, and the Cities plan may disclose the PHI of a deceased person to a coroner, medical examiner, funeral director, or organ procurement organization for certain purposes.

Other uses or disclosures with an authorization

Other uses or disclosures of your PHI will be made only with your written authorization, unless otherwise permitted or required by law. You may revoke an authorization at any time in writing, except to the extent that we have already taken action on the information disclosed or if we are permitted by law to use the information to contest a claim or coverage under the Plan.

Your Rights Regarding Your Protected Health Information

Right To Access Your Protected Health Information You have the right to review or obtain copies of your PHI records, with some limited exceptions. Usually the records include enrollment, billing, claims payment and case or medical management records. Your request to review and/or obtain a copy of your PHI records must be made in writing. Health care carriers, third party administrators, and/or the Cities plan may charge a fee for the costs of producing, copying and mailing your requested information, but you will be informed of the cost in advance.

Right To Amend Your Protected Health Information If you feel that PHI maintained by the Plan is incorrect or incomplete, you may request that we amend the information. Your request must be made in writing and must include the reason you are seeking a change. Health care carriers, third party administrators, and/or the Cities plan may deny your request if, for example, you ask to amend information that was not created by the Plan, as is often the case for health information in our records, or you ask to amend a record that is already accurate and complete.

If health care carriers, third party administrators, and/or the Cities plan deny your request to amend, you will be notified in writing. You then have the right to submit to the health care carrier, third party administrator, and/or the Cities plan a written statement of disagreement with our decision and the health care carrier, third party administrator, and/or the Cities plan have the right to rebut that statement.

Right to an Accounting of Disclosures by the Plan You have the right to request an accounting of disclosures health care carriers, third party administrators, and/or the Cities plan have made of your PHI. The list will not include disclosures related to your treatment, or payment, or health care operations, or disclosures made to you or with your authorization. The list may also exclude certain other disclosures, such as for national security purposes.

Your request for an accounting of disclosures must be made in writing and must state a time period for which you want an accounting. This time period may not be longer than six years and may not include dates before April 14, 2003. Your request should indicate in what form you want the list (for example, on paper or electronically). Health care carriers, third party administrators, and the Cities plan, may charge a fee for providing the accounting disclosures, but you will be informed of the cost in advance.

Right To Request Restrictions on the Use and Disclosure of Your Protected Health Information You have the right to request that health care carriers, third party administrators, and the Cities plan restrict or limit how to use or disclose your PHI for treatment, payment or health care operations. Health care carriers, third party administrators, or the Cities plan may not agree to your request. If it is agreed, we will comply with your request unless the information is needed for an emergency. Your request for a restriction must be made in writing. In your request, you must include (1) what information you want to limit; (2) whether you want to limit how to use or disclose your information, or both; and (3) to whom you want the restrictions to apply.

Right To Receive Confidential Communications You have the right to request that health care carriers, third party administrators, and the Cities plan use a certain method to communicate with you about the plan or that we send plan information to a certain location if the communication could endanger you. Your request to receive confidential communications must be made in writing. Your request must clearly state that all or part of the communication from us could endanger you. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.

Right to a Paper Copy of This Notice You have a right at any time to request a paper copy of this notice, even if you had previously agreed to receive an electronic copy. If you receive this notice on our web site or by electronic mail (e-mail), you are entitled to receive this notice in written form. Please contact the Human Resources Department to obtain a copy of this notice in written form.

Contact Information for Exercising Your Rights You may exercise any of the rights described above by contacting our Privacy Officer. See the end of this Notice for the contact information.

Health Information Security

Health care carriers, third party administrators, and the Cities plan require our employees and business associates to follow the City’s security policies and procedures that limit access to health information about members to those employees and or entities that need it to perform their job responsibilities. In addition, we maintain physical, administrative and technical security measures to safeguard your PHI.

Complaints

If you believe that your privacy rights have been violated, you may file a complaint with the carrier, third party administrator, or the Cities plan as listed below on this page and/or with the Secretary of the Department of Health and Human Services. All complaints to the health care carriers, third party administrators, and the Cities plan, must be made in writing and sent to the address listed below.

CARRIER/TPA/PLAN REQUEST FOR ACCOUNTING RECORD OF DISCLOSURES FILING A COMPLAINT QUESTIONS

City of Redwood City Privacy Officer
CITY OF REDWOOD CITY
Department of Human Resources
1017 Middlefield Road
Redwood City, CA 94063
(650) 780-7282
(650) 364-3539

California Public Employees Retirement System
(PERS) HIPAA Coordinator
CalPERS
P.O. Box 942714
Sacramento, CA 94229-2714
1-888-CalPERS or
1-888-225-7377

TLC Administrators 3340 Walnut Avenue, Suite 290
Fremont, CA 94538-2215
(800) 533-0113

Delta Dental Subscriber Services
P.O. Box 7736
San Francisco, CA 91420
(877) 335-8273

Vision Service Plan VSP.com or
Customer Service
(800) 877-7195

MHN Quality Management Department
1600 Los Gamos Drive, Suite 300
San Rafael, CA 94903
(800) 533-3719 extension 7566

We support your right to protect the privacy of your PHI. We will not retaliate in any way if you choose to file a complaint with us, the health care carriers, or third party administrators listed above, or the Department of Health and Human Services.

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