North Seneca Ambulance, Inc.
1645 North Rd, Waterloo, NY 13165
THIS NOTICE DESCRIBES HOW YOUR MEDICAL INFORMATION
MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO
PLEASE REVIEW THIS NOTICE CAREFULLY.
North Seneca Ambulance EMS, Inc. (the Company) is committed to maintaining the privacy of your protected health information ("PHI"), which includes information about your medical condition and the care and treatment you receive from the Company and other health care providers. This Notice details how your PHI may be used by the Company and disclosed to third parties for purposes of your care, payment for your care, health care operations of the Company, and for other purposes permitted or required by law. This Notice also details your rights regarding your PHI.
USE OR DISCLOSURE OF PHI
1. The Company may use and/or disclose your PHI for purposes related to your care, payment for your care, and health care operations of the Company. The following are examples of the types of uses and/or disclosures of your PHI that may occur. These examples are not meant to include all possible types of use and/or disclosure.
a) Care In order to provide ambulance services in an emergency situation, the Company will provide your PHI to those health care professionals directly involved in your care so that they may understand your medical condition and needs, and provide advice or treatment (e.g., a hospital). For example, the Company will provide the emergency room personnel with an explanation about your condition.
b) Payment In order to get paid for some or all of the services provided by the Company, the Company may provide your PHI, directly or through a billing service, to appropriate third party payors, pursuant to their billing and payment requirements. For example, the Company may need to provide your health insurance carrier or, if you are over 62, the Medicare program with information about the ambulance services provided so that the Company can be properly reimbursed.
c) Health Care Operations In order for the Company to operate in accordance with applicable law, and in order for the Company to provide quality and efficient care, it may be necessary for the Company to compile, use and/or disclose your PHI. For example, the Company may use your PHI in order to evaluate the performance of the Company's personnel in providing care to you.
AUTHORIZATION NOT REQUIRED
1. The Company may use and/or disclose your PHI, without a written Authorization from you, in the following instances:
(a) De-identified Information Your PHI is altered so that it does not identify you and, even without your name, cannot be used to identify you.
(b) Business Associate To a business associate, which is someone who the Company contracts with to provide a service necessary for your treatment, payment for your treatment and health care operations (e.g., billing service). The Company will obtain satisfactory written assurance, in accordance with applicable law, that the business associate will appropriately safeguard your PHI.
(c) Personal Representative To a person who, under applicable law, has the authority to represent you in making decisions related to your health care.
(d) Public Health Activities - Such activities include, for example, information collected by a public health authority, as authorized by law, to prevent or control disease, injury or disability. This includes reports of child abuse or neglect.
(e) Federal Drug Administration - If required by the Food and Drug Administration to report adverse events, product defects or problems or biological product deviations, or to track products, or to enable product recalls, repairs or replacements, or to conduct post marketing surveillance.
(f) Abuse, Neglect or Domestic Violence - To a government authority if the Company is required by law to make such disclosure. If the Company is authorized by law to make such a disclosure, it will do so if it believes that the disclosure is necessary to prevent serious harm or if the Company believes that you have been the victim of abuse, neglect or domestic violence. Any such disclosure will be made in accordance with the requirements of law, which may also involve notice to you of the disclosure.
(g) Health Oversight Activities - Such activities, which must be required by law, involve government agencies involved in oversight activities that relate to the health care system, government benefit programs, government regulatory programs and civil rights law. Those activities include, for example, criminal investigations, audits, disciplinary actions, or general oversight activities relating to the community's health care system.
(h) Judicial and Administrative Proceeding - For example, the Company may be required to disclose your PHI in response to a court order or a lawfully issued subpoena.
(i) Law Enforcement Purposes - In certain instances, your PHI may have to be disclosed to a law enforcement official for law enforcement purposes. Law enforcement purposes include:
(1) complying with a legal process (i.e., subpoena) or as required by law;
(2) information for identification and location purposes (e.g., suspect or missing person);
(3) information regarding a person who is or is suspected to be a crime victim;
(4) in situations where the death of an individual may have resulted from criminal conduct;
(5) in the event of a crime occurring on the premises of the Company; and
(6) a medical emergency (not on the Companies premises) has occurred, and it appears that a crime has occurred. (j) Coroner or Medical Examiner - The Company may disclose your PHI to a coroner or medical examiner for the purpose of identifying you or determining your cause of death, or to a funeral director as permitted by law and as necessary to carry out its duties.
(k) Organ, Eye or Tissue Donation - If you are an organ donor, the Company may disclose your PHI to the entity to whom you have agreed to donate your organs.
(l) Research - If the Company is involved in research activities, your PHI may be used, but such use is subject to numerous governmental requirements intended to protect the privacy of your PHI such as approval of the research by an institutional review board and the requirement that protocols must be followed.
(m) Avert a Threat to Health or Safety - The Company may disclose your PHI if it believes that such disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public and the disclosure is to an individual who is reasonably able to prevent or lessen the threat.
(n) Specialized Government Functions - When the appropriate conditions apply, the Company may use PHI of individuals who are Armed Forces personnel:
(1) for activities deemed necessary by appropriate military command authorities;
(2) for the purpose of a determination by the Company of Veteran Affairs of eligibility for benefits; or
(3) to a foreign military authority if you are a member of that foreign military service. The Company may also disclose your PHI to authorized federal officials for conducting national security and intelligence activities including the provision of protective services to the President or others legally authorized.
(o) Inmates - The Company may disclose your PHI to a correctional institution or a law enforcement official if you are an inmate of that correctional facility and your PHI is necessary to provide care and treatment to you or is necessary for the health and safety of other individuals or inmates.
(p) Workers' Compensation - If you are involved in a Workers' Compensation claim, the Company may be required to disclose your PHI to an individual or entity that is part of the Workers' Compensation system.
(q) Disaster Relief Efforts - The Company may use or disclose your PHI to a public or private entity authorized to assist in disaster relief efforts.
(r) Required by Law - If otherwise required by law, but such use or disclosure will be made in compliance with the law and limited to the requirements of the law.
Uses and/or disclosures, other than those described above, will be made only with your written Authorization, which you may revoke at any time.
The Company may, from time to time, contact you to provide appointment reminders. The reminder may be in the form of a letter or postcard. The Company will try to minimize the amount of information contained in the reminder. The Company may also contact you by phone and, if you are not available, the Company will leave a message for you.
The Company may, from time to time, contact you about treatment alternatives, or other health benefits or services that may be of interest to you.
The Company may only use and/or disclose your PHI for marketing activities if we obtain from you a prior written Authorization. "Marketing" activities include communications to you that encourage you to purchase or use a product or service, and the communication is not made for your care or treatment. However, marketing does not include, for example, sending you a newsletter about this Company. Marketing also includes the receipt by the Company of remuneration, directly or indirectly, from a third party whose product or service is being marketed to you. The Company will inform you if it engages in marketing and will obtain your prior Authorization.
The Company may use and/or disclose some of your PHI in order to contact you for fundraising activities supportive of the Company. Any fundraising materials sent to you will describe how you may opt out of receiving any further communications.
The Company may disclose to your family member, other relative, a close personal friend, or any other person identified by you, your PHI directly relevant to such person's involvement with your care or the payment for your care. The Company may also use or disclose your PHI to notify or assist in the notification (including identifying or locating) a family member, a personal representative, or another person responsible for your care, of your location, general condition or death. However, in both cases, the following conditions will apply:
(a) The Company may use or disclose your PHI if you agree, or if the Company provides you with opportunity to object and you do not object, or if the Company can reasonably infer from the circumstances, based on the exercise of its judgment, that you do not object to the use or disclosure.
(b) If you are not present, the Company will, in the exercise of its judgment, determine whether the use or disclosure is in your best interests and, if so, disclose only the PHI that is directly relevant to the person's involvement with your care.
1. You have the right to:
(a) Revoke any Authorization, in writing, at any time. To request a revocation, you must submit a written request to the Company's Privacy Officer.
(b) Request restrictions on certain use and/or disclosure of your PHI as provided by law. However, the Company is not obligated to agree to any requested restrictions. To request restrictions, you must submit a written request to the Company's Privacy Officer. In your written request, you must inform the Company of what information you want to limit, whether you want to limit the Companies use or disclosure, or both, and to whom you want the limits to apply. If the Company agrees to your request, the Company will comply with your request unless the information is needed in order to provide you with emergency treatment.
(c) Receive confidential communications of PHI by alternative means or at alternative locations. You must make your request in writing to the Company's Privacy Officer. The Company will accommodate all reasonable requests.
(d) Inspect and copy your PHI as provided by law. To inspect and copy your PHI, you must submit a notarized written request to the Company's Privacy Officer. In certain situations that are defined by law, the Company may deny your request, but you will have the right to have the denial reviewed. The Company can charge you a fee for the cost of copying, mailing or other supplies associated with your request.
(e) Amend your PHI as provided by law. To request an amendment, you must submit a notarized written request to the Company's Privacy Officer. You must provide a reason that supports your request. The Company may deny your request if it is not in writing, if you do not provide a reason and support of your request, if the information to be amended was not created by the Company (unless the individual or entity that created the information is no longer available), if the information is not part of your PHI maintained by the Company, if the information is not part of the information you would be permitted to inspect and copy, and/or if the information is accurate and complete. If you disagree with the Companies denial, you have the right to submit a written statement of disagreement.
(f) Receive an accounting of disclosures of your PHI as provided by law. To request an accounting, you must submit a notarized written request to the Company's Privacy Officer. The request must state a time period which may not be longer than six years and may not include the dates before April 14, 2003. The request should indicate in what form you want the list (such as a paper or electronic copy). The first list you request within a 12 month period will be free, but the Company may charge you for the cost of providing additional lists in that same 12 month period. The Company will notify you of the costs involved and you can decide to withdraw or modify your request before any costs are incurred.
(g) Receive a paper copy of this Privacy Notice from the Company upon request to the Company's Privacy Officer.
(h) Complain to the Company, or to the Secretary of Health and Human Services, Office of Civil Rights, Hubert H. Humphrey Building, 200 Independence Avenue, S. W., Room 509F HHH Building, Washington, D.C. 20201. Or you may contact a regional office of the Office of Civil Rights, which can be found at www.hhs.gov/ocr/regmail.html. To file a complaint with the Company, you must contact the Company's Privacy Officer. All complaints must be in writing.
(i) To obtain more information on, or have your questions about your rights answered, you may contact the Company's Privacy Officer, Jay Pelton, at 315-539-5002 or via email at DO@nsaems.org
1. The Company:
(a) Is required by law to maintain the privacy of your PHI and to provide you with this Privacy Notice of the Company's legal duties and privacy practices with respect to your PHI.
(b) Is required to abide by the terms of this Privacy Notice.
(c) Reserves the right to change the terms of this Privacy Notice and to make the new Privacy Notice provisions effective for all of your PHI that it maintains.
(d) Will not retaliate against you for making a complaint.
(e) Must make a good faith effort to obtain from you an acknowledgement of receipt of this Notice, except in emergency situations.
(f) Will post this Privacy Notice on the Company's web site, if the Company maintains a web site.
(g) Will provide this Privacy Notice to you by e-mail if you so request and the Company has the technology to comply. However, you also have the right to obtain a paper copy of this Privacy Notice.
This Notice is effective as of July 07, firstname.lastname@example.org