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.
10/33 Ambulance Service, Ltd. (10/33) is required by law to maintain the privacy of certain confidential 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. 10/33 is also required to abide by the terms of the version of this Notice currently in effect. We are required to do so "as soon as reasonably practicable", which is most likely at the time your statement of account is submitted to you for payment for services rendered by our company.
Uses and Disclosures of PHI
10/33 may use PHI for the purposes of treatment, payment, and healthcare operations, and in most cases without your written permission. Examples of uses of your PHI:
- For Treatment –This includes such things as obtaining verbal and written information about your medical condition and treatment from you as well as from others, such as doctors and nurses who give orders to allow us to provide treatment to you. We may give your PHI to other healthcare providers involved in your treatment , and may transfer your PHI via radio or telephone to the hospital or dispatch center.
- 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 submitting bills to insurance companies, making medical necessity determinations, and collecting 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, as well as certain other management functions.
Use and Disclosure of PHI Without Your Authorization
10/33 is permitted to use PHI without your written authorization, or opportunity to object, in certain situations, and unless prohibited by a more stringent state law, including:
- For the treatment, payment, or healthcare operations of another healthcare provider who treats you;
- For healthcare and legal compliance activities;
- 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 and opportunity to object to such a disclosure and you do not raise an objection, and in certain other circumstances where we are unable to obtain your agreement and believe the disclosure is in your best interests;
- To a public health authority in certain situations as required by law (such as abuse, neglect, or domestic violence);
- 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 and 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 responding to a warrant;
- 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 such 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 and 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;
- We may also 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. 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 with that authorization.
As a patient, you have a number of rights with respect to your PHI, including:
- The Right to Access, Copy, or Inspect Your PHI – This means you may 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 and 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. You also have the right to receive confidential communications of your PHI. If you wish to inspect and copy your medical information, you should contact our Privacy Officer.
- 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 with 60 days of our 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 our Privacy Officer.
- The Right to Request an Accounting- You may request an accounting from us of certain disclosures of your medical information that we have made in the 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, such as a medical facility to which we have transported you to or from. We are also not required to give you an accounting of your uses of PHI for which you have already given us written authorization. If you wish to request an accounting, contact our Privacy Officer.
- 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. 10/33 is not required to agree to any restriction you request, but nay restrictions agreed to by 10/33 in writing are binding on 10/33.
- Internet, Electronic Mail, and the Right to Obtain a Copy of Paper Notice on Request- If we maintain a website, we will prominently post a copy of this Notice on our website. 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 of the Notice- 10/33 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 PHI that we maintain. Any material changes to the Notice will be promptly posted in our facilities and posted to our website if we maintain one. You can get a copy of the latest version of this Notice by contacting our Privacy Officer.
- 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 our Privacy Officer.
Privacy Officer Contact Information
10/33 Ambulance Service, Ltd.
3 Wolfer Industrial Park
Spring Valley, IL 61362
Telephone (815) 664-2032
Fax Number (815) 663-1035