(Effective June 15 2007, click here to read our Third Rider Patient Confidentiality Agreement.)
IMPORTANT: 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.
As an essential part of our
commitment to you, ACTION AMBULANCE SERVICE, INC. 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 ACTION AMBULANCE SERVICE, INC.
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 on our use and
disclosure of your PHI.
ACTION AMBULANCE
SERVICE, INC. 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
are committed to following at all times.
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.
Purpose of this Notice:
ACTION AMBULANCE SERVICE, INC. is required by law to maintain the
privacy of certain confidential health care information, known as
Protected Health Information or PHI, and to provide you with a notice
of our legal duties and privacy practices with respect to your PHI.
This Notice describes your legal rights, advises you of our privacy
practices, and lets you know how ACTION AMBULANCE SERVICE, INC. is
permitted to use and disclose PHI about you.
ACTION AMBULANCE
SERVICE, INC. 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.
Uses and Disclosures of PHI:
ACTION AMBULANCE SERVICE, INC. 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 things
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
determinations and reviews, 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 policies 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 ACTION
AMBULANCE SERVICE, INC. or to provide you with information about our
annual subscription program.
Reminders for Scheduled Transports and Information on Other
Services.
We may also contact you to provide you with a reminder of
any scheduled appointments for non-emergency ambulance and medical
transportation, or for other information about alternative services we
provide or other health-related benefits and services that may be of
interest to you.
Use and Disclosure of PHI Without Your Authorization. ACTION AMBULANCE SERVICE, INC. is permitted to use PHI without
your written authorization, or opportunity to object in certain
situations, including:
·
For
ACTION AMBULANCE SERVICE, INC. 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);
·
To
another health care provider (such as the hospital to which you are
transported) for the health care operations activities of the entity
that receives the information as long as the entity receiving the
information has or has had a relationship with you and the PHI
pertains to that relationship;
·
For
health care fraud and abuse detection or for activities related to
compliance with the law;
·
To a
family member, other relative, or 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 objecting (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 friend 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 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 court 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 and health information will be released only when there is a
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 will 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 we 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 may 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 amend 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 from us 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
purposes 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/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 accounting 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 disclose the PHI to a
health care provider to provide you with emergency treatment. ACTION
AMBULANCE SERVICE, INC. is not required to agree to any restrictions
you request, but any restrictions agreed to by ACTION AMBULANCE
SERVICE, INC. are binding on ACTION AMBULANCE SERVICE, INC.
Internet,
Electronic Mail, and the Right 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: ACTION AMBULANCE SERVICE, INC. reserves the right 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 this Notice
by contacting the Privacy Officer identified below.
Your Legal Rights and Complaints:
You also have the
right to complain to us, or to the Secretary of the United States
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 filing a complaint with us or to the government. Should you
have any questions, comments or complaints you may direct all
inquiries to the privacy officer listed at the end of this Notice.
Individuals will not be retaliated against for filing 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:
Lisa Livingstone, Privacy Officer
Action Ambulance Service, Inc.
844 Woburn Street
Wilmington, Ma 01887
978-253-2600
Effective Date of the Notice:
4/1/03
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