116 Your Personal Representative You may exercise your rights through a personal representative. Your personal representative will be required to produce evidence of authority to act on your behalf before the personal representative will be given access to your PHI or be allowed to take any action for you. Proof of such authority will be a completed, signed and approved Appointment of Personal Representative form. You may obtain this form by calling the Fund Office. The Fund retains 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. The Fund will recognize certain individuals as personal representatives without you having to complete an Appointment of Personal Representative form. For example, absent notice of restrictions under the Fund’s Right to Request Restrictions on the Use and Disclosure Policy and Procedures, the Fund will automatically consider a Spouse to be the personal representative of an individual covered by the plan. In addition, the Fund will consider a parent, guardian or other person acting in loco parentis as the personal representative of an unemancipated minor unless applicable law requires otherwise. A Spouse or a parent may act on an individual’s behalf, including requesting access to their PHI. Spouses and unemancipated minors may, however, request that the Fund restrict access of PHI to family members as described above at the beginning of Section 3 of this Notice. You should also review the Fund’s Policy and Procedure for the Recognition of Personal Representatives for a more complete description of the circumstances where the Fund will automatically consider an individual to be a personal representative. Section 4: The Fund’s Duties Maintaining your Privacy The Fund is required by law to maintain the privacy of your PHI and to provide you and your eligible dependents with notice of its legal duties and privacy practices. This notice is effective beginning on April 14, 2003, and the Fund is required to comply with the terms of this notice. However, the Fund reserves the right to change its privacy practices and to apply the changes to any PHI received or maintained by the Fund prior to that date. If a privacy practice is changed, a revised version of this notice will be provided to you and to all past and present participants and beneficiaries for whom the Fund still maintains PHI. A Privacy Notice will be sent by U.S. Mail. Any revised version of this notice will be distributed within 60 days of the effective date of any material change to: • The uses or disclosures of PHI, • Your individual rights, • The duties of the Plan, or • Other privacy practices stated in this notice.