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NOTICE
OF PRIVACY
IMPORTANT: THIS NOTICE DESCRIBES
HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU
CAN GET ACCESS TO THIS INFORMATION.
As an essential part of our commitment to you, Ajo Ambulance maintains
the privacy of certain confidential health care information about you,
known as Protected Health Information or PHI. We are required by law to
protect your health care information and to provide you with the
attached Notice of Privacy Practices.
The notice outlines our legal duties and privacy practices respect to
your PHI. It not only describes our privacy practices and your legal
rights, but lets you know, among other things, how Ajo Ambulance is
permitted to use and disclose PHI about you, how you can access and
copy that information, how you may request amendment of that
information and how you may request restrictions of our use and
disclosure of your PHI.
Ajo Ambulance is also required to abide by the terms of the version of
this Notice currently in effect. In most situations we may use this
information as described in this Notice without your permission, but
there are some situations where we may use it only after we obtain your
written authorization, if we are required by law to do so. We respect
your privacy and treat all health care information about our patients
with care under strict policies of confidentiality that all of our
staff is committed to following at all times.
USES AND DISCLOSURES OF PHI:
Ajo Ambulance may use PHI for the purposes of treatment, payment and
health care operations, in most cases without your written permission.
Examples of our use of your PHI:
FOR TREATMENT: This includes
such things as verbal and written information that we obtain about you
and use pertaining to your medical condition and treatment provided to
you by us and other medical personnel, including doctors and nurses who
give orders to allow us to provide treatment to you). It also includes
information we give to other health care personnel, to whom we transfer
your care and treatment, and includes transfer of PHI via radio or
telephone to the hospital or dispatch center as well as providing the
hospital with a copy of the written record we create in the course of
providing you with treatment and transport.
FOR PAYMENT: This includes any
activities we must undertake in order to get reimbursed for the
services we provide to you, including such as organizing your PHI and
submitting bills to insurance companies (either directly or through a
third party billing company), management of billed claims for services
rendered, medical necessity determination and review, utilization
review and collection of outstanding accounts.
FOR HEALTH CARE OPERATIONS:
This includes quality assurance activities, licensing and training
programs to ensure that our personnel meet our standards of care and
follow established polices and procedures, obtaining legal and
financial services, conducting business planning, processing grievances
and complaints, creating reports that do not individually identify you
for data collection purposes, fundraising and certain marketing
activities.
FUNDRAISING: We may contact you
when we are in the process of raising funds for Ajo Ambulance or to
provide you with information about our annual subscription program.
REMINDERS FOR SCHEDULED TRANSPORTS
& INFORMATION ABOUT OTHER SERVICES: We may also contact you
to provide you with a reminder of any scheduled appointments for
non-emergency ambulance and medical transports, or with other
information about alternative services were provide or other
health-related benefits and services that may be of interest to you.
USE & DISCLOSURE OF PHI WITHOUT
YOUR AUTHORIZATION: Ambulance is permitted to use PHI without
your written authorization or opportunity to object in certain
situations, including:
For Ajo Ambulance's use in treating you or in obtaining payment
for services provided to you or in other health care operations;
For the treatment activities of another health care provider;
To another health care provider or entity for the payment
activities of the provider or entity that receives the information
(such as your hospital or insurance company);
For health care fraud and abuse detection or for activities
related to compliance with the law;
To a family member, other relative, close personal friend or
other individual involved in your care if we obtain your verbal
agreement to do so or if we give you an opportunity to object to such a
disclosure and you do not raise an objection. We may also disclose
health information to your family, relatives or friends if we infer
from the circumstances that you would not object. For example, we may
assume you agree to our disclosure of your personal health information
to your spouse when your spouse has called the ambulance for you. In
situations where you are not capable of (because you are not present or
due to your incapacity or medical emergency), we may, in our
professional judgment, determine that a disclosure to your family
member, relative or friends is in your best interest. In that
situation, we will disclose only health information relevant to that
person’s involvement in your care. For example, we may inform the
person who accompanied you in the ambulance that you have certain
symptoms and we may give that person an update on your vital signs and
treatment that is being administered by our ambulance crew;
To a public health authority in certain situations (such as
reporting a birth, death or disease as required by law, as part of a
public health investigation, to report a child or adult abuse or
neglect or domestic violence, to report adverse events such as product
defects or to notify a person about exposure to a possible communicable
disease as required by law;
For health oversight activities including audits or government
investigations, inspections, disciplinary proceedings and other
administrative or judicial actions undertaken by the government (or
their contractors) by law to oversee the health care system;
For judicial and administrative proceedings as required by a or
administrative order, or in some cases in response to a subpoena or
other legal process;
For law enforcement activities in limited situations, such as
when there is a warrant for the request or when the information is
needed to locate a suspect or stop a crime;
For military, national defense and security and other special
government functions;
To avert a serious threat to the health and safety of a person or
the public at large;
For workers' compensation purposes and in compliance with
workers' compensation laws;
To coroners, medical examiners and funeral directors for
identifying a deceased person, determining cause of death or carrying
on their duties as authorized by law;
If you are an organ donor, we may release health information to
organizations that handle organ procurement or organ, eye or tissue
transplantation or to an organ donation bank, as necessary to
facilitate organ donation and transplantation;
For research projects, but this will be subject to strict
oversight and approvals. Health information will be released only when
there in minimal risk to your privacy and adequate safeguards are in
place in accordance with the law;
We may use or disclose health information about you in a way that
does not personally identify you or reveal who you are.
Any other use or disclosure of PHI, other than those listed above all
only be made with your written authorization, (the authorization must
specifically identify the information we seek to use or disclose, as
well as when and how we seek to use or disclose it). You may revoke
your authorization at any time, in writing, except to the extent that
we have already used or disclosed medical information in reliance on
that authorization.
PATIENT RIGHTS:
As a patient, you have a number of rights with respect to the
protection of your PHI, including:
The right to access, copy or inspect
your PHI: This means you may come to our offices and inspect and
copy most of the medical information about you that we maintain. We
will normally provide you with access to this information within 30
days of your request. We may also charge you a reasonable fee for you
to copy any medical information that you have the right to access. In
limited circumstances, we may deny you access to your medical
information, and you may appeal certain types of denials. We have
available forms to request access to your PHI and will provide a
written response if we deny you access and let you know your appeal
rights. If you wish to inspect and copy your medical information, you
should contact the privacy officer listed at the end of this Notice.
The right to amend your PHI:
You have the right to ask us to amend written medical information that
we have about you. We will generally amend your information within 60
days of your request and will notify you when we have amended the
information. We are permitted by law to deny your request to your
medical information only in certain circumstances, like when we believe
the information you have asked us to amend is correct. If you wish to
request that we amend the medical information that we have about you,
you should contact the privacy officer listed at the end of this Notice.
The right to request an accounting of
our use and disclosure of your PHI: You may request an
accounting form of certain disclosures of your medical information that
we have made in the last six years prior to the date of your request.
We are not required to give you an accounting of information we have
used or disclosed for purpose of treatment, payment, or health care
operations, or when we share your health information with our business
associates, like our billing company or a medical facility from or to
which we have transported you.
We are also not required to give you an accounting of our uses of
protected health information for which you have already given us
written authorization. If you wish to request an accounting of the
medical information about you that we have used or disclosed that is
not exempted from the account requirement, you should contact the
privacy officer listed at the end of this Notice.
The right to request that we restrict
the uses and disclosures of your PHI: You have the right to
request that we restrict how we use and disclose your medical
information that we have about you for treatment, payment or health
care operations, or to restrict the information that is provided to
family, friends and other individuals involved in your health care. But
if you request a restriction and the information you asked us to
restrict is needed to provide you with emergency treatment, then we may
use the PHI or disclosed the PHI to a health care provider to provide
you with emergency treatment. Ajo Ambulance is not required to agree to
any restrictions you request, but any restrictions agreed to by Ajo
Ambulance are binding on Ajo Ambulance.
Internet, Electronic Mail and the
Rights to Obtain Copy of Paper Notice on Request: If we maintain
a web site, we will prominently post a copy of this Notice on our web
site and make the Notice available electronically through the web site.
If you allow us, we will forward you this Notice by electronic mail
instead of on paper and you may always request a paper copy of the
Notice.
Revisions to the Notice: Ajo
Ambulance reserves the rights to change the terms of this Notice at any
time and the changes will be effective immediately and will apply to
all protected health information that we maintain. Any material changes
to the Notice will be promptly posted in our facilities and posted to
our web site if we maintain one. You can get a copy of the latest
version of the Notice by contacting the privacy officer listed below.
Your Legal Rights and Complaints: You
also have the right to complain to us or to the Secretary of the United
State Department of Health and Human Services if you believe your
privacy rights have been violated. You will not be retaliated against
in any way for filling a complaint with us or to the government. Should
you have any questions, comments or complaints you may direct all
inquires to the privacy officer listed at the end of this Notice.
Individuals will not be retaliated against for filling a complaint.
If you have any questions or if you wish to file a complaint or
exercise any rights listed in this Notice, please contact:
Privacy
Officer
Ajo Ambulance Inc.
410 Malacate St.
Ajo, AZ 85321
Phone: 520-387-5154 Fax: 520-387-6050
Effective Date of this Notice:
April
14, 2003
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return to Ajo Ambulance's home page, click here.