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Saint
Clair Veterans Memorial Ambulance Fund
Privacy
Statement
SAINT
CLAIR VETERANS MEMORIAL AMBULANCE FUND
PRIVACY NOTICE
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, Saint Clair
Veterans Memorial Ambulance Fund 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 Saint Clair
Veterans Memorial Ambulance Fund 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.
Saint
Clair Veterans Memorial Ambulance Fund 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.
PLEASE
READ THE ATTACHED DETAILED NOTICE.
IF YOU HAVE ANY QUESTIONS ABOUT IT, PLEASE CONTACT
STEPHEN J. BOBELLA JR., OUR PRIVACY OFFICER, AT (570)
628-9765.
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:
Saint
Clair Veterans Memorial Ambulance Fund 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 Saint Clair Veterans Memorial Ambulance Fund is
permitted to use and disclose PHI about you.
Saint
Clair Veterans Memorial Ambulance Fund 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:
Saint Clair Veterans Memorial Ambulance Fund 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 Saint Clair Veterans Memorial Ambulance Fund, 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.
Saint Clair Veterans Memorial Ambulance Fund is
permitted to use PHI without your written
authorization, or opportunity to object in certain situations,
including:
·
For Saint Clair Veterans Memorial Ambulance Fund’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);
·
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. Saint
Clair Veterans Memorial Ambulance Fund is not required to
agree to any restrictions you request, but any restrictions
agreed to by Saint Clair Veterans Memorial Ambulance Fund are
binding on Saint Clair Veterans Memorial Ambulance Fund.
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:
Saint Clair Veterans Memorial Ambulance Fund 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:
STEPHEN
BOBELLA JR.
PO BOX 124
SAINT CLAIR, PA. 17970
(570) 628-9765
Effective
Date of the Notice:
April 14, 2003
If you
received this notice via mail, fax or electronic submission
please complete the following information and send it back to
our organization at PO Box 124; Saint Clair, Pa. 17970. Please
tear at the perforated line.
I acknowledge
the receipt of the Saint Clair Veterans Memorial Ambulance
Fund Privacy Notice.
Printed
Name:___________________________
Signature________________________________
Date you
utilized our services:
_____________________________________________________________
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