Your Rights
Under HIPAA
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:
Sauk Prairie Ambulance Association is required by law to
maintain the privacy of certain healthcare 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 Sauk Prairie Ambulance Association is
permitted to use and disclose PHI about you.
Sauk Prairie Ambulance Association 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 you written
authorization, if we are required by law to do so.
Uses and Disclosures of PHI:
Sauk Prairie Ambulance Association may use PHI for the
purposes of treatment, payment and healthcare 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 healthcare
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, utilization review, and collection of outstanding
accounts.
For Healthcare 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.
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:
Sauk Prairie Ambulance Association is permitted to use PHI
without your written authorization or opportunity to object in
certain situations, including:
·
For Sauk Prairie Ambulance Association’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 healthcare 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 healthcare provider (such as the hospital to which you
are transported) for the healthcare 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 healthcare 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 healthcare 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; 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 office 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 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 that
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
healthcare 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 PHI 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 healthcare operations, or to restrict the
information that is provided to family, friends and other
individuals involved in your healthcare.
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
healthcare provider to provide you with emergency treatment.
Sauk Prairie Ambulance Association is not required to agree
to any restrictions you request, but any restrictions agreed to by
Sauk Prairie Ambulance Association are binding
on Sauk Prairie Ambulance Association.
Internet, Electronic Mail, and the Right to Obtain a 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:
Sauk Prairie Ambulance Association 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 listed 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.
If you have any questions or if you wish to file a complaint or
exercise any rights listed in this Notice, please contact:
Sauk Prairie Ambulance Association
110 Washington Street
Sauk City, WI 53583
608.643.4183
Effective Date of this Notice:
April 14, 2003
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