NOTICE OF PRIVACY PRACTICES
Midway Fire Rescue
Effective Date: April 14, 2003
Responsibilities of Midway Fire Rescue
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN ACCESS THIS INFORMATION.
PLEASE REVIEW IT CAREFULLY
Midway Fire Rescue is required to protect the privacy of health information about you, which may identify you. This information is called “protected health information” which includes health care services that are provided to you, payment for those health care services or other health care operations provided on your behalf. This agency is required by law to inform you of our privacy protections through this Notice of Privacy Practices that explains our legal duties and privacy practices with respect to your protected health information. This document describes the ways we may use and disclose your past, present and future protected health information; ensuring that we use and/or disclose this information only as we have described in this Notice. We do, however, reserve the right to change our privacy practices and the terms of this Notice, and to make the new Notice provisions effective for all protected health information that it maintains prior to issuing a revised Notice. Any changes to this Notice will be posted in our offices and stations. Copies of any revised Notices will be available to you upon request. If at any time, you have questions or concerns about the information in this Notice or about our agency’s privacy policies, procedures and, you may contact our agency Privacy Officerat 843-545-3620.
Use and Disclosure of Protected Health Information Without Authorization
Midway Fire Rescue may use or disclose your protected health information, as needed, in order to provide, coordinate or manage your health care and related services. This includes communicating with other health care providers, both within and outside this agency, regarding your treatment when we need to coordinate and manage your health care. Example: We will share your protected health information with doctors, nurses and other health care personnel who are involved in providing your health care. For example, we need to provide protected health care information to the facilities that we are transporting you to/from so that your care is continuous and appropriate. Normally, this disclosure will be in person, by radio, or by phone. Disclosing your health information to another health care provider would be especially important if your doctor knew you had allergic reactions to particular substances that could be life-threatening. So sharing your protected health information with another health care provider is essential for your protection and quality care.
Payment for Services
Midway Fire Rescue may use and give your health information to other staff and health plans you designate to bill and collect payment for the health care services received by you. We may share information with your health plan to determine coverage status prior to scheduled services. We will share adequate information with departments that prepare bills and manage client accounts in order to ensure payment for services rendered. We may share your health information with agents of your insurance company or health plan to confirm services that were provided to you. We may also share your health information with facility staff who review client services to make certain you have received appropriate care and treatment. Portions of your health information could be shared with consumer reporting agencies that study health care trends.Example: The treatment provided to you needs to be shared with our agency’s billing company and with your health plan so that your bill can be paid, or you can be reimbursed if you paid the bill up front. We may also send your health information to our agency staff who review the care you received by the agency, to make certain you received the appropriate care and treatment for your health problem.
Health Care Operations
Midway Fire Rescue may use or disclose your protected health information in performing a variety of business activities that we call “health care operations”. These “health care operations” allow us to improve the quality of care we provide to you and our other clients and help us to reduce health care costs. Some examples of the way we may use or disclose your protected health information for “health care operations” include the following:
• Reviewing the care you received and evaluating the performance of our personnel to ensure you have received quality care.
Example: We may use information from review of your protected health information to assist our personnel treating other patientswith similar problems.
• Improving health care and lowering costs for groups of clients who have similar health problems and to help manage and coordinate
Example: We may use your protected health information and the protected health information of other clients with similar health
problems to identify the most successful treatment modalities.
• Reviewing and evaluating the skills, qualifications and performance of personnel that are taking care of you.
Example: We may use your protected health information to review the treatment you received to ensure you received quality care.
• Providing training programs for students, trainees, health care providers or non-health care professionals (such as billing clerks) that
allow these professionals to use the skills they have learned.
Example: We may allow your protected health information to be used for training professionals in improving their diagnostic and
• Cooperating with outside organizations that review and determine the quality of care that we, and other health care organizations,
Example: We may use your protected health information by allowing government agencies or licensing agencies to review such
information to ensure you received quality care.
• Cooperating with outside organizations that evaluate, certify or license health care providers, staff or facilities in a particular field or
Example: We may use your protected health information for educational purposes, so that staff may fulfill requirements for
• Assisting others who review our activities.
Example: We may use your protected health information when allowing other health care providers, lawyers and others who assist us
in complying with specific laws.
• Planning for our agency’s future operations
Example: We may use your protected health information, along with other clients’ protected health information to make decisions
about future needs for our agency, such as adding EMS stations in a particular area.
• Resolving grievances within our agency.
Example: We may use your protected health information to enhance investigations conducted by administration whenever a staff
member within our agency files a grievance, protesting against a particular issue.
Midway Fire Rescue may use and/or disclose your protected health information for a number of circumstances in which you do not have to give authorization or
otherwise have an opportunity to agree or object. These are circumstances that the government has determined to be so important that protected health information may
be disclosed without the client’s permission. Those circumstances include:
• Use or disclosure required by law
• Use or disclosure that is necessary for public health activities
• Use or disclosure regarding abuse, neglect or domestic violence
• Use or disclosure for health oversight activities
• Use or disclosure for law enforcement purposes
• Use or disclosure for court proceedings
• Use or disclosure relating to death
• Use or disclosure relating to cadaver organs, eye or tissue donations
• Use or disclosure relating to medical research
• Use or disclosure to avert a threat to health or safety
• Use or disclosure relating to specialized government functions
• Use or disclosure to correctional/custodial situations
• Use or disclosure for Worker’s Compensation
Use and Disclosure of Protected Health Information That Allows You An Opportunity To Object
Midway Fire Rescue will not use or disclose your protected health information without your authorization, except as stated above. There are certain situations where we will use or disclose such information if we tell you in advance of our intention and you do not object. Examples of such situations are as follows:
To families, friends or others involved in your care
Example: We may share with a family member, relative, friend or other person identified by you, your protected health information
that is directly related to that persons involvement in your care or payment for your care, such as your spouse.
Example: We may share with a family member, personal representative or other person responsible for your care, your protected
health information necessary to notify such individuals of your location and general condition in order to keep them involved with
your care and treatment.To public or private agencies
Example: We may share your protected health information with the American Red Cross for disaster relief purposes.
If you would like to object to our use or disclosure about your protected health information in any of the above situations, please
contact this agency’s Privacy Officer listed in this Notice. We will agree to such an objection and not disclose your protected health information except in certain circumstances, such as in an emergency situation, or if you are a minor, or if you have been adjudicated incompetent, in which case we may or may not be able to agree to your request.
Use and Disclosure of Protected Health Information That Requires Your Authorization
Midway Fire Rescue will not use or disclose your protected health information without your authorization except as allowed in the above examples. For all other uses or disclosures, we will ask you to sign a written authorization allowing us to share or request your protected health information. Before you sign an authorization you will be fully informed of the exact information you are authorizing to be disclosed and to whom you are authorizing to disclose such information. If you decide to cancel your authorization, you may do so by advising Midway Fire Rescue that you do not want any additional protected health information about you exchanged with this particular person/agency. You will be asked to sign and date the Authorization Revocation section of your original authorization. Your authorization will then be considered invalid at that point in time; however, any actions that were taken on the authorization prior to the time you cancelled your authorization are legal and binding.
Your Rights Regarding Your Protected Health Information
Midway Fire Rescue clients have certain rights regarding their protected health information that is created and maintained by this agency.
Right to receive a copy of this Notice You have a right to receive a copy of Midway Fire Rescue Service’s Notice of Privacy Practices. At your first treatment Encounter with this agency, you will be given a copy of this Notice and asked to sign acknowledgement that you have received it. In
the event of emergency services, you will be provided the Notice as soon as possible after emergency services have been rendered.
In addition, copies of this Notice have been posted in public areas in our Offices and stations. You have the right to request a paper
copy of this Notice at any time from our agency’s Privacy Officer.
Right to request different ways to communicate with you
You have the right to request to be contacted at a different location or by a different method. For example, you may request all written
information be sent to your work address rather than your home address. We will agree with your request as long as it is reasonable to
do so; however, your request must be made in writing and forwarded to our agency Privacy Officer.
Right to request to see and copy your protected health information
You have the right to request to see and receive a copy of your protected health information in clinical, billing and other records that
are used to make decisions about you. Your request must be in writing and forwarded to our agency Privacy Officer. If your request
is approved, you may be charged a fee to cover the cost of the copy, excluding labor costs. Instead of providing you with a full copy of the protected health information, we may give you a summary or explanation of your protected health information, if you agree in advance to that format and to the cost of such information. Your request may be denied under certain circumstances. If we do deny your request, we will explain our reason for doing so in writing and describe any rights you may have to request a review of our denial.
Right to request amendment of your protected health information
You have the right to request changes in your health information in clinical, billing and other records used to make decisions about
you. If you believe that we have information that is either inaccurate or incomplete, you may submit a request in writing to our
agency Privacy Officer and explain your reasons for the amendment. We must respond to your request within 60 days of receiving
We may deny your request if:
• the information was not created by this agency (unless you prove the creator of the information is no longer available to change the
• the information is not part of the records used to make decisions about you;
• we believe the information is correct and complete; or
• you do not have the right to see and copy the record.
If we deny your request to change your protected health information, we will tell you in writing the reasons for denial and describe
your rights to give us a written statement disagreeing with the denial. If we accept your request to change your protected health information, we will make reasonable
efforts to inform others of the changes, including persons you name who have received your protected health information and who need the changes.
Right to request a listing of disclosures we have made
You have the right to request and receive a written list of certain disclosures of your protected health information, made after April 14,
2003. You may ask for disclosures we made up to six years before your request. This listing will include the date of the disclosure,
the name (and address, if available) of the person or organization receiving the information, a brief description of the information
disclosed and the purpose of the disclosure.
This agency is not required to include on the list disclosures for the following:
• For your treatment;
• For billing and collection of payment for your treatment;
• For our health care operations;
• Requested by you, that you authorized, or which are made to individuals involved in your care; or
• Allowed by law.
Your first request for a listing of disclosures will be provided to you free of charge. However, if you request a listing of disclosures
more than once in a 12 month period, you may be charged a reasonable fee. We will inform you of the cost involved and you may
choose to withdraw or modify your request at that time, before any costs are incurred.
Right to request restrictions on uses and disclosures of your protected health information
You have the right to request that we limit our use and disclosure of your protected health information for treatment, payment and
health care operations. You also have the right to request a limit on the health information we disclose about you to someone who is
involved in your care or the payment of your care, such as a family member or a friend. For example, you could ask that we not use or
disclose the information about a previous condition you had. We are not required to agree to such request. However, if we do agree, we must follow the agreed upon
restriction (unless the information is necessary for emergency treatment or unless it is a disclosure to the U.S. Secretary of the Department of Health and Human
Services). You or you personal representative may cancel the restrictions at any time. In addition, this agency may cancel a restriction at any time, as long as we notify
you of the cancellation.
If you believe your privacy rights have been violated by us, or if you want to complain to us about our privacy practices, you may contact our agency Privacy Officer.
All complaints should be submitted in writing. Contact information is as follows:
Midway Fire Rescue Privacy Officer Peggy Green
67 Saint Pauls Place
Pawleys Island, SC 29585
843 545-3620 Phone
843 545-3073 Fax
E –mail email@example.com
You may also send a written complaint to the United States Secretary of the Department of Health and Human Services. Contact
information is as follows:
Office for Civil Rights
U.S. Department of Health and Human Services
Atlanta Federal Center, Suite 3B70
61 Forsyth Street, S.W.
Atlanta, GA 30303-8909
Voice Phone (404)562-7886
If you file a complaint, we will not take any action against you or change our treatment.