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Universal Mfg. Co. – Notice of Privacy Practices

Effective Date: March 1, 2013

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.

The Universal Mfg. Co. Group Medical Plan (the “Plan”), which includes medical and flexible spending account coverages offered under the Universal Mfg. Co. Plans, are required by law (under the Administrative Simplification provision of the Health Insurance Portability and Accountability Act of 1996 HIPAA’s privacy rule) to take reasonable steps to ensure the privacy of your personally identifiable health information. This Notice is being provided to inform you of the policies and procedures Universal Mfg. Co. has implemented and your rights under them, as well as under HIPAA. These policies are meant to prevent any unnecessary disclosure of your health information.

Use and Disclosure of Your Health Information by the Plan that Do Not Require Your Authorization: The plan may use or disclose your health information (that is protected health information (PHI), as defined by HIPAA’s privacy rule) for:

1. Payment and Health Care Operations: In order to make coverage determinations and payment (including, but not limited to, billing, claims management, subrogation, and plan reimbursement). For example, the Plan may provide information regarding your coverage or health care treatment to other health plans to coordinate payment of benefits. Your health information may also be used or disclosed in order for the Plan to carry out its own operations regarding the administration of the Plan and provide coverage and services to the Plan’s participants. For example, the Plan may use your health information to project future benefit costs, to determine premiums, conduct or arrange for case management or medical review, for internal grievances, for auditing purposes, business planning and management activities such as planning related analysis, or to contract for stop-loss coverage. Pursuant to the Genetic Information Non-Discrimination Act (GINA), the Plan does not use or disclose genetic information for underwriting purposes.

2. Disclosure to the Plan Sponsor: As required, in order to administer benefits under the Plan. The Plan may also provide health information to the plan sponsor to allow the plan sponsor to solicit premium bids from health insurers, to modify the Plan, or to amend the Plan.

3. Requirements of Law: When required to do so by any federal, state or local law.

4. Health Oversight Activities: To a health oversight agency for activities such as audits, investigations, inspections, licensure, and other proceedings related to the oversight of the health plan.

5. Threats to Health or Safety: As required by law, to public health authorities if the Plan, in good faith, believes the disclosure is necessary to prevent or lessen a serious or imminent threat to your health or safety or to the health and safety of the public.

6. Judicial and Administrative Proceedings: In the course of any administrative or judicial proceeding in response to an order from a court or administrative tribunal, in response to a subpoena, discovery request or other similar process. The Plan will make a good faith attempt to provide written notice to you to allow you to raise an objection.

7. Law Enforcement Purposes: To a law enforcement official for certain enforcement purposes, including, but not limited to, the purpose of identifying or locating a suspect, fugitive, material witness or missing person.

8. Coroners, Medical Examiners, or Funeral Directors: For the purpose of identifying a deceased person, determining a cause of death or other duties as authorized by law.

9. Organ or Tissue Donation: If you are an organ or tissue donor, for purposes related to that donation.

10. Specified Government Functions: For military, national security and intelligence activities, protective services, and correctional institutions and inmates.

11. Workers’ Compensation: As necessary to comply with workers’ compensation or other similar programs.

12. Distribution of Health-Related Benefits and Services: To provide information to you on health-related benefits and services that may be of interest to you.

Notice in Case of Breach

Universal Mfg. Co. is required maintain the privacy of your PHI; provide you with this notice of its legal duties and privacy practices with respect to PHI; and to notify you of any breach of your PHI.

Use and Disclosure of Your Health Information by the Plan that Does Require Your Authorization: Other than as listed above, the Plan will not use or disclose without your written authorization. You may revoke your authorization in writing at any time, and the Plan will no longer be able to use or disclose the health information. However, the Plan will not be able to take back any disclosures already made in accordance with the Authorization prior to its revocation. The following uses and disclosures will be made only with authorization from the individual: (i) most uses and disclosures of psychotherapy notes (if recorded by a covered entity); (ii) uses and disclosures of PHI for marketing purposes, including subsidized treatment communications; (iii) disclosures that constitute a sale of PHI; and (iv) other uses and disclosures not described in this notice

Your Rights with Respect to Your Health Information: You have the following rights under the Plan’s policies and procedures, and as required by HIPAA’s privacy rule:

Right to Request Restrictions on Uses and Disclosures: You may request the Plan to restrict uses and disclosures of your health information. The Plan will accommodate reasonable requests; however, it is not required to agree to the request, unless it is for services paid completely by you of your own pocket. If you wish to request a restriction, please send it in writing to HIPAA Privacy Officer, at Universal Mfg. Co., 405 Diagonal St., Algona, IA 50511, Phone 515-295-3557.

Right to Inspect and Copy Your Health Information: You may inspect and obtain a copy of your health information the Plan maintains. The requested information will be provided within 30 days if the information is maintained on site or within 60 days if the information is maintained offsite. A single 30-day extension is allowed if the Plan is unable to comply with the deadline. A written request must be provided to HIPAA Privacy Officer Universal Mfg. Co., 405 Diagonal St., Algona, IA 50511, Phone 515-295-3557. If you request a copy of your health information, the Plan may charge a reasonable fee for copying, assembling costs and postage, if applicable, associated with your request.

Right to Amend Your Health Information: You may request the Plan to amend your health information if you feel that it is incorrect or incomplete. The Plan has 60 days after the request is made to make the amendment. A single 30-day extension is allowed if the Plan is unable to comply with this deadline. A written request must be provided to HIPAA Privacy Officer, Universal Mfg. Co., 405 Diagonal St., Algona, IA 50511, Phone 515-295-3557. Your request may be denied in whole or part and, if so, the Plan will provide you with a written explanation of the denial.

Right to an Accounting of Disclosures: You may request a list of disclosures made by the Plan of your health information during the six years prior to your request (or for a specified shorter period of time), however, the list will not include disclosures made: (1) to carry out treatment, payment or health care operations; (2) disclosures made prior to April 14, 2004; (3) to individuals about their own health information; and (4) disclosures for which you provided a valid authorization.

A request for an accounting form must be used to make the request and can be obtained by contacting your HIPAA Privacy Officer Universal Mfg. Co. Officer Universal Mfg. Co., 405 Diagonal St., Algona, IA 50511, Phone 515-295-3557. The accounting will be provided within 60 days from your submission of the request form. An additional 30 days is allowed if this deadline cannot be met.

Right to Receive Confidential Communications: You may request that the Plan communicate with you about your health information in a certain way or at a certain location if you feel the disclosure could endanger you. You must provide the request in writing to your HIPAA Privacy Officer Universal Mfg. Co., 405 Diagonal St., Algona, IA 50511, Phone 515-295-3557. The Plan will attempt to honor all reasonable requests.

Right to a Paper Copy of this Notice: You may request a paper copy of this Notice at any time, even if you have agreed to receive this Notice electronically. Please contact your HIPAA Privacy Officer Universal Mfg. Co., 405 Diagonal St., Algona, IA 50511, Phone 515-295-3557 to make this request.

The Plan’s Duties: The Plan is required by law to maintain the privacy of your health information as related in this Notice and to provide this Notice to you of its duties and privacy practices. The Plan is required to abide by the terms of this Notice, which may be amended from time to time. The Plan reserves the right to change the terms of this Notice and to make the new Notice provisions effective for all health information that it maintains.

Complaints and Contact Person: If you wish to exercise your rights under this Notice, communicate with the Plan about its privacy policies and procedures, or file a complaint with the Plan, please contact the HIPAA Contact Person, at Universal Mfg. Co. 405 Diagonal St., Algona, IA 50511, Phone 515-295-3557. You may also file a complaint with the Secretary of Health and Human Services if you believe your privacy rights have been violated.

Any questions/concerns should be directed to the HIPAA Privacy Officer, at Universal Mfg. Co., 405 Diagonal St., Algona, IA 50511, Phone 515-295-3557.


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