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NOTICE OF PRIVACY PRACTICES
This notice describes how medical information about
you may be used and disclosed and how you can get
access to this information. Please review carefully.
If
you have any questions about this notice, please
contact EMS Officer Athena Robbins.
This Notice of Privacy Practices describes how we
may use and disclose your protected health
information to carry out treatment, payment or
health care operations and for other purposes that
are permitted or required by law. It also describes
your rights to access and control your protected
health information. Protected health information
means health information, including demographic
information, collected from me and created or
received by my physician, another health care
provider, health plan, my employer or a health care
clearinghouse. This protected health information
relates to my past, present or future physical or
mental health or condition and identifies me, or
there is a reasonable basis to believe the
information may identify me.
We
are required to abide by the terms of this Notice of
Privacy Practices. We may change the terms of our
notice, at any time. The new notice will be
effective for all protected health information that
we may obtain at that time. Upon your request, we
will provide you with any revised notice of privacy
practices by calling the office and requesting that
a revised copy be sent to you in the mail.
1.
Uses and Disclosures of Protected Health Information
Based Upon your Written Consent
The
Bellbrook Fire/EMS Department will use or disclose
protected health information for the following
purposes:
Treatment:
We will use and disclose your protected health
information to provide, coordinate, or manage your
health care and any related services. For example,
we would disclose your protected health information,
as necessary, to your physician or to the Emergency
Department who is treating you. We will also
disclose protected health information to other
physicians who may be treating you. For example,
your protected health information may be provided to
a physician to whom you have been referred.
Payment:
Your protected health information will be used to
obtain payment for your health care services. This
may include certain activities that your health
insurance plan may undertake before it approves or
pays for your health care services, such as making a
determination of eligibility or coverage for
insurance benefits, reviewing services provided to
you for medical necessity, and undertaking
utilization review activities.
Health Care Operations:
We may use or disclose your protected health
information in order to support the business
activities of the Fire Department. These activities
include, but are not limited to, the day-to-day
running of the Department, quality assessments,
employee reviews, training of medical students,
licensing, marketing, and fundraising, and
conducting or arranging for other business
activities.
For
example, we may disclose your protected health
information to medical students who are preceptors
from approved programs.
We
will share your protected health information with
third party "business associates" that perform
various activities (e.g., billing, transcription
services) for the Fire Department. Whenever an
arrangement between the Fire Department and a
business associate involves the use or disclosure of
your protected health information, we will have a
written contract that contains terms that will
protect the privacy of your protected health
information.
We
may use or disclose your protected health
information to provide you with information about
treatment, alternatives or other health-related
benefits and services that may be of interest to
you. We may also use and disclose your protected
health information for other marketing activities.
For example, your name and address may be used to
send you a newsletter about the services we offer.
We may also send you information about products and
services that we believe may be beneficial to you.
You may contact our privacy contact to request that
these materials not be sent to you.
We
may use or disclose your demographic information and
the dates that you received treatment, as necessary,
in order to contact you for fundraising activities
supported by our office. If you do not want to
receive these materials, please contact our privacy
contact and request that these fundraising materials
then be sent to you.
2.
Uses and Disclosures of Protected Health Information
Based Upon your Written Authorization
Other uses and disclosures of your protected health
information will be made only with your written
authorization, unless otherwise permitted or
required by law as described below. You may revoke
this authorization, at any time, in writing, except
to the extent that the Fire Department has taken an
action in reliance on the use or disclosure
indicated in the authorization.
3.
Other Permitted and Required Uses and Disclosures
that may be made with your Consent, Authorization,
or Opportunity to Object
We
may use and disclose your protected health
information in the following instances. You have the
opportunity to agree or object to the use or
disclosure of all or part of your protected health
information. If you are not present or able to agree
or object to the use or disclosure of the protected
health information, then the Fire Division may,
using professional judgment, determine whether the
disclosure is in your best interest. In this case,
only the protected health information that is
relevant to your health care will be disclosed.
4.
Other Permitted and Required Uses and Disclosures
that may be made without your Consent,
Authorization, or Opportunity to Object
We
may use or disclose protected health information in
these following situations without your consent or
authorization. These situations include:
Required by Law:
We may use and disclose your protected health
information if the use or disclosure is required by
law. The use or disclosure will be made in
compliance with the law.
Public Health:
We may disclose your protected health information to
public health authorities for purposes related to
controlling disease, injury or disability. This
includes:
-
Communicable Diseases: We may disclose your
protected health information to a person who may
have been exposed to a communicable disease or
may otherwise be at risk of contracting or
spreading the disease or condition.
-
Health Oversight: We may disclose your protected
health information for activities such as
audits, investigations and inspections by
government oversight agencies.
-
Abuse or Neglect: We may disclose your protected
health information to report child abuse or
neglect. In addition, we may disclose your
protected health information if we believe that
you have been a victim of abuse, neglect or
domestic violence.
Food and Drug Administration: We may disclose your protected health information to report
adverse events and product defects or problems; to
enable product recalls; or to make repairs or
replacements.
Legal Proceedings:
We may disclose your protected health information in
the course of any judicial or administrative
proceeding.
Law Enforcement:
We may also disclose protected health information to
a law enforcement official for purposes such as
legal proceedings; request for identification and
location of a suspect, fugitive, material witness or
missing person; pertaining to victims of a crime;
and medical emergency that is likely that a crime
has occurred.
Coroners and Funeral Directors: We may disclose protected health information to a coroner or medical
examiner for identification purposes, determining
cause of death or for the coroner or medical
examiner to perform other duties. We may also
disclose protected health information to a funeral
director, in order to permit the funeral director to
carry out their duties. We may disclose such
information in reasonable anticipation of death.
Organ Donation:
We may disclose protected health information to
organizations involved in organ and tissue donation
and transplant.
Research:
We may disclose your protected health information to
researchers when their research has been approved by
an institutional review board that has reviewed the
research proposal and establish protocols to insure
the privacy of your protected health information.
Criminal Activity:
We may disclose protected health information, if we
believe that the use of disclosure is necessary to
prevent or lessen a serious and eminent threat to
the health or safety of a person or the public.
Military Activity and National Security: We may use or disclose your protected health information to
individuals who are armed forces personnel for
activities deemed necessary by appropriate military
command authorities, or for the purpose of a
determination by the Department of Veterans Affairs
of your eligibility for benefits. We may disclose
your protected health information to authorized
federal officials for conducting national security
and intelligence activities, including for the
provision of protective services to the President or
others legally authorized.
Workers' Compensation:
Your protected health information may be disclosed
by us as authorized to comply with Workersı
Compensation laws and other similar
legally-established programs.
Correctional Facilities:
We may use or disclose your protected health
information if you are an inmate of a correctional
facility and the Fire Division created or received
your protected health information in the course of
providing care to you.
5.
Others Involved in your Health Care
Unless you object, we may disclose to a member of
your family, a relative, a close friend or any other
person you identify, your protected health
information that directly relates to that personıs
involvement in your health care. We may disclose
protected health information to notify or assist in
notifying a family member, personal representative
or any other person that is responsible for your
care, location, or death. Finally, we may disclose
protected health information to an authorized public
or private entity to assist in disaster relief
efforts.
Emergencies:
We may use or disclose your protected health
information in an emergency situation.
Communication Barriers:
We may use and disclose your protected health
information if your physician or another physician
in the practice attempts to obtain consent from you
but is unable to do so due to communication barriers
and the physician determines that you intend to
consent to use or disclose under the circumstances.
6.
Your Health Information Rights
You have the Right to Inspect and Copy your
Protected Health Information:
This means you may inspect and obtain a copy of
protected health information about you for as long
as we maintain the protected health information.
Under federal law, there may be instances where you
may not inspect or copy your protected health
information. Depending on the circumstances, a
decision to deny access may be reviewable. Please
contact our privacy contact if you have any
questions about access to your protected health
information.
You have the Right to Request a Restriction of your
Protected Health Information:
This means you may ask us not to use or disclose any
part of your protected health information for the
purposes of treatment, payment or health care
operations. You may also request that any part of
your protected health information not be disclosed
to family members or friends who may be involved in
your care or for notification purposes as described
in this Notice of Privacy Practices. Your request
must state the specific restriction requested and to
whom you want the restriction to apply.
The
Fire Department is not required to agree to a
restriction that you may request. If the Fire
Department believes it is in your best interest to
permit use and disclosure of your protected health
information, your protected health information will
not be restricted. If the Fire Department does agree
to the requested restriction, we may not use or
disclose your protected health information in
violation of that restriction unless it is needed to
provide emergency treatment. With this in mind
please discuss any restriction you wish to request
with the Fire Department.
You have the Right to Request to Receive
Confidential Communications from us by Alternative
means or at an Alternative Location:
We will accommodate reasonable requests. Please make
this request in writing to our privacy contact.
You may have the right to have the Fire Division
amend your protected health information:
This means you may request to have your protected
health information changed for as long as we
maintain this information. In certain cases, we may
deny your request to have your protected health
information changed. If we deny your request for a
change, you have the right to disagree with us.
Please contact our privacy contact if you have
questions about making changes to your protected
health information and how you can disagree with our
decision.
You have the right to receive an accounting of
certain disclosures we have made, if any, of your
protected health information:
This right applies to disclosures for purposes other
than treatment, payment or healthcare operations as
described in this Notice of Privacy Practices. It
excludes disclosures we may have made to you, family
members or friends involved in your care or for
notification purposes. The right to receive this
information is subject to certain exceptions,
restrictions and limitations.
You have the right to obtain a paper copy of this
notice from us:
If you would like to have a more detailed
explanation of these rights or if you would like to
exercise one or more of these rights, contact our
privacy contact.
7.
Complaints
You
may complain to us or to the Secretary of Health and
Human Services if you believe your privacy rights
have been violated by us. You may file a complaint
with us by notifying our privacy contact of your
complaint. We will not retaliate against you for
filing a complaint.
You
may contact our privacy contact, EMS Officer, Athena
Robbins, at (937) 848-3272 for further information
about the complaint process.
8.
Change of Ownership
In
the event that the Bellbrook Fire/EMS Department is
merged with another organization, your protected
health information/medical record will become the
property of the new organization.
This notice was published and becomes effective on April 14, 2003. |
