9/1/06
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
If you have any questions about this notice, please contact
Ira
M. Hart III
Director
332
North
620-532-5624
620-532-1293
Fax
E-mail
kingmanems@terraworld.net
www.cityofkingman.com/ems.html
OUR PLEDGE REGARDING
MEDICAL INFORMATION
We are committed to protecting the confidentiality of medical information about you. We create a record of the care and services you receive from Kingman Emergency Medical Services. We need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records generated by our Emergency Medical Technicians.
This notice will tell you about the ways in which we may use and disclose medical information about you. We also describe your rights and certain obligations we have regarding the use and disclosure of medical information.
We are required by law to:
• make sure that medical information that identifies you is kept private;
• give you this notice of our legal duties and privacy practices with respect to medical information about you, and make a good faith effort to obtain your acknowledgement of receipt of this notice; and
• follow the terms of the notice that is currently in effect.
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YOUR RIGHTS REGARDING YOUR MEDICAL
INFORMATION.
Right To Inspect and Copy. You have the right to inspect and copy medical information that may be used to make decisions about your care. Usually, this includes medical and billing records.
To inspect and copy medical information that may be used to make decisions about you, you must submit your request in writing to Ira M. Hart III, Director of EMS. If you request a copy of the information, we may charge a fee for the costs of copying, mailing, or other supplies and services associated with your request.
We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to medical information, you may request that the denial be reviewed. Another certified technician chosen by Kingman EMS will review your request and the denial. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review.
Right To Amend If you believe that medical information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by or for Kingman EMS.
To request an amendment, your request must be made in writing and submitted to Ira M. Hart III, Director of EMS. In addition, you must provide a reason that supports your request.
We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that:
• Was not created by us, unless the person or entity that created the information is no longer available to make the amendment;
• Is not part of the medical information kept by or for Kingman EMS,
• Is not part of the information that you would be permitted to inspect and copy; or
• Is accurate and complete.
Right To an Accounting Of Disclosures. You have the right to request an “accounting of disclosures.” This is a list of the disclosures we made of medical information about you, with certain exceptions specifically defined by law.
To request this list or accounting of disclosures, you must submit your request in writing to Ira M. Hart III, Director of EMS. Your request must state a time period which may not be longer than six years and may not include dates before April 14, 2003. Your request should indicate in what form you want the list (for example, on paper, electronically). The first list you request within a 12 month period will be free. For additional lists, we may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.
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Right To Request Restrictions. You have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment, payment, or health care operations. You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend. For example, you could ask that we not use or disclose information about a surgery you had.
We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment.
To request restrictions, you must make your request in writing to Ira M. Hart III, Director of EMS. In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit our use, disclosure or both; and (3) to whom you want the limits to apply, for example, disclosures to your spouse.
Right To Request Confidential Communications You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail.
To request confidential communications, you must make your request in writing to Ira M. Hart III, Director of EMS. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.
Right To a Paper Copy Of This Notice You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice.
You may obtain a copy of this notice at our website, www.cityofkingman.com/ems.html
To obtain a paper copy of this notice, contact Ira M. Hart III, Director of EMS.
COMPLAINTS
If you believe your rights with respect to medical information about you have been violated by Kingman EMS, you may file a complaint with Kingman EMS or with the Secretary of the Department of Health and Human Services. To file a complaint with Kingman EMS, contact Ira M. Hart III, Director of EMS. All complaints must be submitted in writing.
You will not be penalized
for filing a complaint.
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HOW WE MAY USE AND
DISCLOSE MEDICAL INFORMATION ABOUT YOU.
The following categories describe different ways that we are permitted to use and disclose medical information without a specific authorization from you.
For Treatment. We may use medical information about you to provide you with medical treatment or services. We may disclose medical information about you to doctors, nurses, technicians, medical students, or other personnel who are involved in taking care of you.
We also may disclose medical information about you to people outside our service who may be involved in your medical care, such as family members, friends, or others used to provide services that are part of your care.
We may disclose medical information about you to other health care providers who request such information for purposes of providing medical treatment to you.
For Payment. We may use and disclose medical information about you so that the treatment and services you receive may be billed to and payment may be collected from you, an insurance company or a third party. For example, we may need to give your health plan information about services you received at so your health plan will pay us or reimburse you for the service.
We also may provide information about you to other health care providers to assist them in obtaining payment for treatment and service provided to you by that provider. We may also provide information to a health plan for purposes of arranging payment for treatment and services provided to you.
For
Health Care Operations. We
may use and disclose medical information about you for service operations.
These uses and disclosures are necessary to run the service and make sure that
all of our patients receive quality care. For example, we may use medical
information to review our treatment and services and to evaluate the
performance of our staff in caring for you. We may also combine medical
information about many
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Treatment Alternatives. We may use and disclose medical information to tell you about or recommend possible treatment options or alternatives that may be of interest to you.
Health-Related Benefits and Services. We may use and disclose medical information to tell you about health-related benefits or services that may be of interest to you.
Fundraising Activities. We may use medical information about you to contact you in an effort to raise money for the service and its operations. We may disclose medical information to a foundation related to the service so that the foundation may contact you in raising money for the service. We would only release contact information, such as your name; address and phone number and the dates you received treatment or services. If you do not want the service to contact you for fundraising efforts, you must notify Ira M. Hart III, Director of EMS, in writing.
Individuals Involved In Your Care or Payment For Your Care. We may release medical information about you to a friend or family member who is involved in your medical care. We may also give information to someone who helps pay for your care. We may also tell your family or friends your condition and that you are in the hospital. In addition, we may disclose medical information about you to an organization assisting in a disaster relief effort so that your family can be notified about your condition, status, and location.
Research. Under certain circumstances, we may use and disclose medical information about you for research purposes. For example, a research project may involve comparing the health and recovery of all patients who received one medication to those who received another, for the same condition. All research projects, however, are subject to a special approval process. This process evaluates a proposed research project and its use of medical information, trying to balance the research needs with patients’ need for privacy of their medical information. Before we use or disclose medical information for research, the project will have been approved through this research approval process, but we may, however, disclose medical information about you to people preparing to conduct a research project, for example, to help them look for patients with specific medical needs, so long as the medical information they review does not leave the EMS office. We will almost always ask for your specific permission if the researcher will have access to your name, address, or other information that reveals who you are, or will be involved in your care.
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As Required By Law. We will disclose medical information about you when required to do so by federal, state, or local law.
To Avert a Serious Threat to Health or Safety. We may use and disclose medical information 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. Any disclosure, however, would only be to someone able to help prevent the threat.
Organ and Tissue Donation. If you are an organ donor, we may use or disclose medical information to organizations that handle organ procurement or organ, eye or tissue transplantation or to an organ donation bank, as necessary to facilitate organ or tissue donation and transplantation.
Military and Veterans. If you are a member of the armed forces, we may release medical information about you as required by military command authorities. We may also release medical information about foreign military personnel to the appropriate foreign military authority.
Employers. We may release medical information about you to your employer if we provide health care services to you at the request of your employer, and the health care services are provided either to conduct an evaluation relating to medical surveillance of the workplace or to evaluate whether you have a work-related illness or injury. In such circumstances, we will give you written notice of such release of information to your employer. Any other disclosures to your employer will be made only if you execute a specific authorization for the release of that information to your employer.
Workers’ Compensation. We may release medical information about you for workers’ compensation or similar programs. These programs provide benefits for work-related injuries or illness.
Public Health Risks. We may disclose medical information about you for public health activities. These activities generally include the following:
• to prevent or control disease, injury or disability;
• to report births and deaths;
• to report child abuse or neglect;
• to report reactions to medications or problems with products;
• to notify people of recalls of products they may be using;
• to notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition;
• to notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect or domestic violence. We will only make this disclosure if you agree or when required or authorized by law.
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Health Oversight Activities. We may disclose medical information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.
Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, we may disclose medical information about you in response to a court or administrative order. We may also disclose medical information about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.
Law Enforcement. We may release medical information if asked to do so by a law enforcement official:
• In response to a court order, subpoena, warrant, summons or similar process,
• To identify or locate a suspect, fugitive, material witness, or missing person,
• About the victim of a crime if, under certain limited circumstances, we are unable to obtain the person’s agreement,
• About a death we believe may be the result of criminal conduct,
• About criminal conduct occurring during the performance of duty, and
• In emergency circumstances to report a crime, the location of the crime or victims, or the identity, description or location of the person who committed the crime.
Coroners, Medical Examiners and Funera1 Directors. We may release medical information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death.
National Security and Intelligence Activities. We may release medical information about you to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized-by law.
Protective Services for the President and Others. We may disclose medical information 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.
Inmates. If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release medical information about you to the correctional institution or law enforcement official. This release would be necessary (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) for the safety and security of the correctional institution.
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OTHER USES
OF MEDICAL INFORMATION.
Other uses and disclosures of medical information not covered by this notice or the laws that apply to us will be made only with your written authorization. If you provide us authorization to use or disclose medical information about you, you may revoke that authorization, in writing, at any time. If you revoke your authorization, we will no longer use or disclose medical information about you for the reasons covered by your written authorization. Of course, we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provided to you.
CHANGES
TO THIS NOTICE.
We reserve the right to change this notice. We reserve the right to
make the revised or changed notice effective for medical information we already
have about you as well as any information we receive in the future. We will
post a copy of the current notice in the
ACKNOWLEDGEMENT.
You will be asked to provide a written acknowledgement of your receipt of this Notice Of Privacy Practices. We are required by law to make a good faith effort to provide you with our Notice Of Privacy Practices and obtain such acknowledgement from you. However, your receipt of care and treatment is not conditioned upon your providing the written acknowledgement.
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