Pittsford Volunteer Ambulance Inc
NOTICE OF PRIVACY PRACTICES
Effective: April 14, 2003 .
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 .
Pittsford Volunteer Ambulance is required by law to maintain the privacy of your Protected Health Information ("PHI") and to provide individuals with you with a notice of our legal duties and privacy practices with respect to PHI. PHI is information about you, including basic demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services. This Notice of Privacy Practices ("Notice") describes how we may use and disclose PHI about you to carry out treatment, payment or health care operations and for other specified purposes that are permitted or required by law. The Notice also describes your rights with respect to PHI about you about you . .
Pittsford Volunteer Ambulance is required to follow the terms of this Notice. We will not use or disclose PHI about you without your written authorization, except as described in this Notice. We reserve the right to change our practices and this Notice and to make the new Notice effective for all PHI we maintain. Upon request, we will provide any revised Notice to you.
Your Health Information Rights
You have the following rights with respect to PHI about you:
Obtain a paper copy of the Notice upon request . You may request a copy of this Notice at any time. Even if you have agreed to receive the Notice electronically, you are still entitled to a paper copy. To obtain a paper copy, write: Privacy Officer, Pittsford Volunteer Ambulance, PO BOX 122, Pittsford, NY 14534.
Request a restriction on certain uses and disclosures of PHI. You have the right to request additional restrictions on our use or disclosure of PHI about you by sending a written request to: Privacy Officer, Pittsford Volunteer Ambulance at the above address. We are not required to agree to those restrictions. For example, if you request a restriction and the requested information is needed to provide you with emergency care, then we may use the PHI or disclose the PHI to a health care provider responsible for your emergency care.
Inspect and obtain a copy of PHI. You have the right to access and copy PHI about you contained in a designated record set for as long as Pittsford Volunteer Ambulance maintains the PHI. To inspect or copy PHI about you, you must send a written request to Privacy Officer, Pittsford Volunteer Ambulance at the above address. We may charge you a fee for the costs of copying, mailing and supplies that are necessary to fulfill your request. We may deny your request to inspect and copy in certain limited circumstances. If you are denied access to PHI about you, you may request that the denial be reviewed. We will normally respond to this request within 30 days.
Request an amendment of PHI . If you feel that PHI we maintain about you is incomplete or incorrect, you may request that we amend it. You may request an amendment for as long as we maintain the PHI. To request an amendment, you must send a written request to Privacy Officer, Pittsford Volunteer Ambulance at the above address. You must include a reason that supports your request. In certain cases, we may deny your request for amendment. If we deny your request for amendment, you have the right to file a statement of disagreement with the decision and we may give a rebuttal to your statement. You may expect a response to your request within 60 days.
Receive an accounting of disclosures of PHI. You have the right to receive an accounting of the disclosures we have made of PHI about you after April 14, 2003 for most purposes other than treatment, payment, or health care operations. The accounting will exclude certain disclosures , such as disclosures we have made directly to you, disclosures you authorize, disclosures to friends or family members involved in your care, and disclosures for notification purposes. The right to receive an accounting is subject to certain other exceptions, restrictions, and limitations. To request an accounting, you must submit a request in writing to Privacy Officer, Pittsford Volunteer Ambulance at the above address. Your request must specify the time period, but may not be longer than six years. The first accounting you request within a 12 month period will be provided free of charge, but you may be charged for the cost of providing additional accountings. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time.
Request communications of PHI by alternative means or at alternative locations. For instance, you may request that we contact you about medical matters only in writing or at a different residence or post office box. To request confidential communication of PHI about you, you must submit a request in writing to Privacy Officer, Pittsford Volunteer Ambulance at the above address. Your request must state how or where you would like to be contacted. We will accommodate all reasonable requests.
Examples of How We May Use and Disclose PHI
The following are descriptions and examples of ways we use and disclose PHI : about you .
We will use PHI for treatment . Example : We may obtain verbal and written information about your medical condition from you and others, such as medical providers who gave orders to allow us to provide treatment. We may give your PHI to other health care providers involved in your treatment, and may transfer your PHI via radio or telephone to the hospital, Office of Emergency Communication and/or Pittsford Volunteer Ambulance Base.
We will use PHI for payment . Example : While Pittsford Volunteer Ambulance provides service at no cost to the patient there might be occasions where we would need to use your PHI to reimburse another agency for services that they provide to you while you are being transported to the hospital on our ambulance.
We will use PHI for health care operations . Example : This includes quality assurance activities, licensing and training programs to ensure that our personnel meet standards of care and follow established policies and procedures, as well as certain management functions.
We are likely to use or disclose PHI for the following purposes:
Business associates : There are some services provided by us through contracts with business associates . An example is our dispatch software vendor. When these services are contracted for, we may disclose PHI about you to our business associate so that they can perform the job we have asked them to do. To protect PHI about you, we require the business associate to appropriately safeguard the PHI.
Communication with individuals involved in your care or payment for your care: Pittsford Volunteer Ambulance crews, using their professional judgment, may disclose to a family member, other relative, close personal friend or any person you identify, PHI relevant to that person's involvement in your care.
Personal communications: We may contact you to provide information about health-related benefits and services that may be of interest to you. We may contact you to inquire about the level of professional service provided to you by Pittsford Volunteer Ambulance crews allowing us to maintain the high level of care provided to our residents.
Workers' compensation: We may disclose PHI about you as authorized by and as necessary to comply with laws relating to workers' compensation or similar programs established by law.
Public health: As required by law, we may disclose PHI about you to public health or legal authorities charged with preventing or controlling disease, injury, or disability.
Law enforcement: We may disclose PHI about you for law enforcement purposes as required by law or in response to a valid subpoena or other legal process.
As required by law: We will disclose PHI about you when required to do so by law.
Health oversight activities : We may disclose PHI about you to an oversight agency for activities authorized by law. These oversight activities include audits, investigations, and inspections, as necessary for our licensure and for the government to monitor the health care system, government programs, and compliance with civil rights laws.
Judicial and administrative proceedings: If you are involved in a lawsuit or a dispute, we may disclose PHI about you in response to a court or administrative order. We may also disclose PHI about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only after efforts have been made to tell you about the request or to obtain an order protecting the requested PHI.
We are permitted to use or disclose PHI about you for the following purposes:
Research : We may disclose PHI about you to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your information.
Coroners, medical examiners, and funeral directors : We may release PHI about you to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also disclose PHI to funeral directors consistent with applicable law to carry out their duties.
Notification: We may use or disclose PHI about you to notify or assist in notifying a family member, personal representative, or another person responsible for your care, your location, and your general condition.
Correctional institution: If you are or become an inmate of a correctional institution, we may disclose PHI to the institution or its agents when necessary for your health or the health and safety of others.
To avert a serious threat to health or safety: We may use and disclose PHI about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person.
Military and veterans : If you are a member of the armed forces, we may release PHI about you as required by U.S. military command authorities. We may also release PHI about foreign military personnel to the appropriate military authority.
National security and intelligence activities: We may release PHI about you to authorized federal officials for intelligence, counterintelligence, and other national security activities as authorized by law.
Protective services for the President and others : We may disclose PHI about you to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state or conduct special investigations.
Victims of abuse, neglect, or domestic violence : We may disclose PHI about you to a government authority, such as a social service or protective services agency, if we reasonably believe you are a victim of abuse, neglect, or domestic violence. We will only disclose this type of information to the extent required by law, or if you agree to the disclosure, or if the disclosure is allowed by law and we believe it is necessary to prevent serious harm to you or someone else or if the law enforcement or public official that is to receive the report represents that it is necessary and will not be used against you.
Other Uses and Disclosures of PHI
Pittsford Volunteer Ambulance will obtain your written authorization before using or disclosing PHI about you for purposes other than those provided for above ( or as otherwise permitted or required by law ) . You may revoke an this authorization in writing at any time. Upon receipt of the written revocation, we will stop using or disclosing PHI about you, except to the extent that we have already taken action in reliance on the authorization.
For More Information or to Report a Problem
If you have questions or would like additional information about Pittsford Volunteer Ambulance's privacy practices, you may contact the Privacy Officer, Pittsford Volunteer Ambulance, PO Box 122, Pittsford, NY 14534.
If you believe your privacy rights have been violated, you can file a complaint by writing Privacy Officer, Pittsford Volunteer Ambulance at the above address or by writing the Secretary of Health and Human Services. There will be no retaliation for filing a complaint.
For Questions or inquiries please contact: privacyofficer@pittsfordambulance.org
