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HIPAA - Notice of Privacy Practice

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.

Use and Disclosure of Health Information

The Teamsters Local 170 Health & Welfare Fund may use your health information, that is, information that constitutes protected health information as defined in the Privacy Rule of the Administrative Simplification provision of the Health Insurance Portability and Accountability Act of 1996 ("HIPPA'), for purposes of making or obtaining payment for your care and conducting health care operations. The Fund has established a policy to guard against unnecessary disclosure of your health information.

THE FOLLOWING IS A SUMMARY OF THE CIRCUMSTANCES UNDER WHICH AND PURPOSES FOR WHICH, YOUR HEALTH INFORMATION MAY BE USED AND DISCLOSED:

To Make or Obtain Payment
The Teamsters Local 170 Health & Welfare Fund may use or disclose your health information to make payment to or collect payment from third parties, such as other health plans or providers, for the care you receive. For example, The Teamsters Local 170 Health & Welfare Fund may provide information regarding your coverage or health care treatment to other health plans to coordinate payment of benefits.

To Conduct Health Care Operations
The Teamsters Local 170 Health & Welfare Fund may use or disclose health information for its own operations to facilitate the administration of The Fund and as necessary to provide coverage and services to all of The Fund's participants. Health care operations includes such activities as:

Eligibility

Enrollment/Disenrollment

Quality assessment and improvement activities.

Activities designed to improve health or reduce health care costs.

Contacting health care providers and participants with information about treatment alternatives and other related functions.

Underwriting, premium rating or related functions to created, renew or replace health insurance or health benefits.

Review and auditing, including compliance reviews, medical reviews, legal services and compliance programs.

Business planning and development including cost management and planning related analysis and formulary development.

Business management and general administrative activities of The Fund, including customer service and resolution of internal grievances.

For example, the Teamsters Local 170 Health & Welfare Fund may use your health information to engage in customer service and grievance resolution.

For Distribution of Health-Related Benefits and Services
The Fund may use or disclose your health information to provide you with information on health-related benefits and services that may be of interest to you.

For Disclosure to the Plan Sponsor
The Fund may disclose your health information to the plan sponsor for administration functions performed by the plan sponsor on behalf of The Fund. In addition, The Fund may provide summary health information to the plan sponsor so that the plan sponsor may solicit premium bids from other health insurers or modify, amend or terminate the plan. The Fund may also disclose to the Plan Sponsor information on whether you are participating in the health plan.

When Legally Required
The Fund will disclose your health information when it is required to do so by any federal, state or local law.

To Conduct Health Oversight Activities
The Fund may disclose your health information to a health oversight agency for authorized activities including audits, civil administrative or criminal investigations, inspections, licensure or disciplinary action. The Fund, however, may not disclose your health information if you are the subject of an investigation and the investigation does not arise out of or is not directly related to your receipt of health care or public benefits.

In Connection With Judicial and Administrative Proceedings
As permitted or required by state law, The Fund may disclose your health information in the course of any judicial or administrative proceeding in response to an order of a court or administrative tribunal as expressly authorized by such order or in response to a subpoena, discovery request or other lawful process, but only when The Fund makes reasonable efforts to either notify you about the request or to obtain an order protecting your health information.

For Law Enforcement Purposes
As permitted or required by state law, The Fund may disclose your health information to a law enforcement official for certain law enforcement purposes, including, but not limited to, if The Fund has a suspicion that your death was the result of criminal conduct or in an emergency to report a crime.

In the Event of a Serious Threat to Health or Safety
The Fund may, consistent with applicable law and ethical standards of conduct, disclose your health information if The Fund, in good faith, believes that such disclosure is necessary to prevent or lessen a serious and imminent threat to your health or safety or to the health and safety of the public.

For Specified Government Functions
In certain circumstances, federal regulations require The Fund to use or disclose your health information to facilitate specified government functions related to the military and veterans, national security and intelligence activities, protective services for the president and others, and correctional institutions and inmates.

For Worker's Compensation
The Fund may release your health information to the extent necessary to comply with laws related to worker's compensation or similar programs.

Authorization to use or Disclose Health Information

Other than as stated above, The Fund will not disclose your health information other than with your written authorization. If you authorize The Fund to use or disclose your health information, you may revoke that authorization in writing at any time.

Your Rights with Respect to your Health Information

You have the following rights regarding your health information that The Teamsters Local 170 Health & Welfare maintains:

Right to Request Restrictions
You may request restrictions on certain uses and disclosures of your health information. You have the right to request a limit on The Fund's disclosure of your health information to someone involved in the payment of your care. However, The Fund is not required to agree to your request. If you wish to make a request for restrictions, please contact the Privacy Officer (508) 791-3416.

Right to Receive Confidential Communications
You have the right to request that The Fund communicate with you in a certain way if you feel the disclosure of your health information could endanger you. For example, you may ask that The Fund only communicate with you at a certain telephone number or by email. If you wish to receive confidential communications, please make your request in writing to:

Privacy Officer
Teamsters Local 170 Health & Welfare Fund
PO Box 1046
Worcester, MA 01613
Fax (508) 792-0936

The Fund will attempt to honor your reasonable requests for confidential communications.

Right to Inspect and Copy Your Health Information
You have the Fight to inspect and copy your health information. A request to inspect and copy records containing your health information must be made in writing to:

Privacy Officer
Teamsters Local 170 Health & Welfare Fund
PO Box 1046
Worcester, MA 01613
Fax (508) 792-0936

If you request a copy of your health information, The Fund may charge a reasonable fee for copying, assembling costs and postage, if applicable, associated with your request.

Right to Amend Your Health Information
If you believe that your health information records are inaccurate or incomplete, you may request that The Fund amend the records. That request may be made as long as the information is maintained by The Fund. A request for an amendment of records must be made in writing to:

Privacy Officer
Teamsters Local 170 Health & Welfare Fund
PO Box 1046
Worcester, MA 01613
Fax (508) 792-0936

The Fund may deny the request if it does not include a reason to support the amendment. The request may also be denied if your health information records were nor created by The Fund, if the health information you are requesting to amend is not part of The Fund's records, if the health information you wish to amend falls within an exception to the health information you are permitted to inspect and copy, or if The Fund determines the records containing your health information are accurate and complete.

Right to an Accounting
You have the right to request a list of certain disclosures of your health information that The Fund is required to keep a record of, under the Privacy Rule, such disclosures for public purposes authorized by law or disclosures that are not in accordance with The Fund's privacy policies and applicable law. The request must be made in writing to:

Privacy Officer
Teamsters Local 170 Health & Welfare Fund
PO Box 1046
Worcester, MA 01613
Fax (508) 792-0936

The request should specify the time period for which you are requesting the information, but may not start earlier than April 14, 2003. Accounting requests may not be made for periods of time going back more than six (6) years. The Fund will provide the first accounting you request during any 12-month period without charge. Subsequent accounting requests may be subject to a reasonable cost-based fee. The Fund will inform you in advance of the fee, if applicable.

Right to a Paper Copy of this Notice
You have a right to request and receive a paper copy of this Notice at any time, even if you have received this Notice previously or agreed to receive the Notice electronically. To obtain a paper copy, please contact the Privacy Officer (508) 791-3416. You may also obtain a copy of the current version of The Fund's Privacy Notice on our" Web site www.Teamsterhwf.com

Duties of Health Plan

The Teamsters Local 170 Health & Welfare Fund is required by law to maintain the privacy of your health information as set forth in this Notice and to provide to you this Notice of its duties and privacy practices. The Fund is required to abide by the terns of this Notice, which may be amended from time to time. The Fund reserves the right to change the terns of this Notice and to make the new Notice provisions effective for all health information that it maintains. If The Fund changes its policies and procedures, The Fund will revise the Notice and will provide a copy of the revised Notice to you within 60 days of the change. You have the right to express complaints to The Fund and to the Secretary of the Department o£ Health and Human Services if you believe that your privacy rights have been violated. Any complaints to The Fund should be made in writing to the Privacy Officer Teamsters Local 170 Health & Welfare Fund PO Box 1046 Worcester, MA 01613 Fax (508) 792-0936. The Fund encourages you to express any concerns you may have regarding the privacy of your information. You will not be retaliated against in any way for filing a complaint.

CONTACT PERSON

The Teamsters Local 170 Health & Welfare Fund has designated the Privacy Officer as its contact person for all issues regarding your privacy and your privacy rights. You may contact this person at:

Teamsters Local 170 Health & Welfare Fund
PO Box 1046
Worcester, MA 01613
Telephone (508) 791-3416

EFFECTIVE DATE

This Notice is effective April 14, 2003

IF YOU HAVE ANY QUESTIONS REGARDING THIS NOTICE, PLEASE CONTACT:

Privacy Officer
Teamsters Local 170 Health & Welfare Fund
PO Box 1046
Worcester, MA 01613
Telephone (508) 791-3416
Fax (508) 792-0936 SG 2/7/03

PLAN SPONSOR RESTRICTIONS

The Teamsters Local 170 Health & Welfare Fund ("Plan") as required under the Administrative Simplification requirements of the Health Insurance Portability and Accountability Act of 1996 ("HIPAA"), allows the disclosure of Protected Health Information ("PHI") as defined under HIPAA, to a Plan Sponsor for the purposes specified below.

1. Disclosure of PHI to Plan Sponsor. Plan shall disclose PHI to a Plan Sponsor only to the extent necessary for a Plan Sponsor to perform the following Plan administrative functions:

At the present time the Plan Sponsor does not perform any administrative functions.

2. Use and Disclosure of PHI bv Plan Sponsor. A Plan Sponsor shall use and/or disclose PHI only to the extent necessary to perform the following Plan Administration functions, which it performs on behalf of the Plan:

At the present time the Plan Sponsor does not perform any administrative functions.

3. Plan Sponsor Certification. The Plan agrees that it will only disclose PHI to a Plan Sponsor upon receipt of a certification that this addendum has been adopted and the Plan Sponsor agrees to abide by such conditions. A Plan Sponsor is subject to the following:

i. Prohibition on Unauthorized Use or Disclosure of PHI. A Plan Sponsor will not use or disclose any PHI received from the Plan, except as permitted in these documents or required by law.

ii. Subcontractors and Agents. A Plan Sponsor will require each of its subcontractors or agents to whom the Plan Sponsor may provide PHI to agree to written contractual provisions that impose at least the same obligations to protect PHI as are imposed on the Plan Sponsor.

iii. Permitted Purposes. A Plan Sponsor will not use or disclose PHI for employment-related actions and decisions or in connection with any other of Plan Sponsor's benefits or employee benefit plans.

iv. Reporting. A Plan Sponsor will report to the Plan any impermissible or improper use or disclosure of PHI not authorized by the plan documents.

v. Access to PHI bv Participants. A Plan Sponsor will make PHI available to the Plan to permit participants to inspect and copy their PHI contained in the designated record set.

vi. Correction of PHI. A Plan Sponsor will make a participant's PHI available to the Plan to permit participants to amend or correct PHI contained in the designated record set that is inaccurate or incomplete and Plan Sponsor will incorporate amendments provided by the Plan.

vii. Accounting of PHI. A Plan Sponsor will make a participant's PHI available to permit the Plan to provide an accounting of disclosures.

viii. Disclosure to Government Agencies. A Plan Sponsor will make its internal practices, books and records relating to the use and disclosure of PHI available to the Plan and to DHHS or its designee for the purpose of determining the Plan's compliance with HIPAA.

ix. Return or Destruction of Health Information. When the PHI is no longer needed for the purpose for which disclosure was made, a Plan Sponsor must, if feasible, return to the Plan or destroy all PHI that the Plan Sponsor received from or on behalf of the Plan. This includes all copies in any form, including any compilations derived from the PHI. If return or destruction is not feasible, the Plan Sponsor agrees to restrict and limit further uses and disclosures to the purposes that make the return or destruction infeasible.

x. Minimum Necessary Requests. A Plan Sponsor will use best efforts to request only the minimum necessary type and amount of PHI to carry out the functions for which the information is requested.

4. Adequate Separation. A Plan Sponsor must represent that adequate separation exists between the Plan and Plan Sponsor so that PHI will be used only for plan administration. The following employees or persons under the control of the Plan Sponsor have access to participants' PHI for the purposes set forth under number 1 above:

At the present time the Plan Sponsor does not perform administrative functions. There are no employees or persons who have access to participants PHI for the purposes wet forth in number 1.

5. Adequate Separation Certification. The Plan requires a Plan Sponsor to certify that the employees identified above are the only employees that will access and use participants PHI! A Plan Sponsor must further certify that such employees will only access and use PHI for the purposes set forth under number 1 above.

At the present time all administrative functions are performed solely by the employees of the Teamsters Local 170 Health & Welfare Fund.

6. Reports of Non-Compliance. Anyone who suspects an improper use or disclosure of PHI may report the occurrence to the Plan's Privacy Official at (508) 791-3416.