Folcroft Fire Company Ambulance Service

Patient Privacy Notice

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.

Purpose of this Notice:  The Folcroft Fire Company Ambulance Service is required by law to maintain the privacy of certain confidential health care 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. This Notice describes your legal rights, advises you of our privacy practices, and lets you know how the Folcroft Fire Company Ambulance Service is permitted to use and disclose PHI about you.  Folcroft Fire Company Ambulance Service is also required to abide by the terms of the version of this Notice currently in effect.

Uses and Disclosures of PHI without your authorization: Folcroft Fire Company Ambulance Service is authorized to use PHI without your authorization or written permission in certain situations, including:

· For treatment including verbal and written information pertaining to your medical condition, information to other healthcare personnel to whom we transfer your care and treatment, and the transfer of PHI via radio or telephone to the hospital;

· For payment including any activities undertaken in order to get reimbursed for services we provide to you, including submission of bills to insurance companies, management of billed claims for services rendered, medical necessity determinations and reviews, and the collection of outstanding accounts;

· For health care operations including quality assurance activities, licensing, training programs, obtaining legal and financial services, business planning, processing grievances and complaints, fundraising, and certain marketing activities.

· Reminders of scheduled transport including contacting you with reminders of scheduled appointments and non-emergency transportation.

· Emergency situations (in these situations, in accordance with the law we will attempt to get your written Authorization after the emergency service is provided and we would appreciate your cooperation when we do so);

· To a relative, friend or individual involved in your care;

· To a public health authority in certain situations (such as reporting a birth, death or disease as required by law, as part of a public health investigation, to report child or adult abuse or neglect or domestic violence, to report adverse events such as product defects, organ transplantation, for the purposes of research in conjunction with the Human Subjects Review Board, or to notify a person about exposure to a possible communicable disease as required by law;

· 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 health care system;

· For judicial and administrative proceedings as 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 there is a warrant for the request, or when the information is needed to locate a suspect or stop a crime;

· 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, in compliance with workers’ compensation laws.

Any other use or disclosure of PHI, other than those listed above, will only be made with your written authorization.  An authorization specifically identifies the information we seek to use or disclose, as well as when and how we seek to use or disclose it.  You may revoke your authorization any time, in writing, except to the extent that we have already used or disclosed medical information in reliance on that authorization.   

Patient Rights:  As a patient, you have a number of rights with respect to the protection of your PHI, including:

The right to access, copy, or inspect your PHI.  This means you may come to our offices and 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 any medical information that you have the right to access.  In limited circumstances, we may deny you access to your medical information, and certain types of denials may be appealed.  We have available forms to request PHI and will provide a written response if we deny you access and let you know your appeal rights.  If you wish to inspect and copy your medical information, you should contact the privacy officer listed at the end of this Notice. 

The right to amend your PHI.  You have the right to ask us to amend written medical information we may have about you.  We will generally amend your information within 60 days of your 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.  You can appeal our denial of your request to amend the information.  If you wish to amend the medical information that we have about you, you should contact the privacy officer listed at the end of this Notice.

The right to request an accounting of our use and disclosures of your PHI.  You may request an accounting from us of certain disclosures of your medical information that we have made in the last 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 health care operations, or of uses or disclosures made prior to April 14, 2003.  If you wish to request an accounting of the medical information about you that we have used or disclosed, you should contact the privacy officer listed at the end of this Notice.

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 for treatment, payment or health care operations, or to restrict the information that is provided to family, friends and other individuals involved in your health care.  The Folcroft Fire Company Ambulance Service is not required to agree to any restrictions you request, but any restrictions agreed to by the Folcroft Fire Company Ambulance Service are binding, with the exception of releasing your PHI in an emergency situation.

Legal Rights and Complaints:  Notice of any changes in Folcroft Fire Company Ambulance Service’s privacy policy may be updated directly on this Notice.

You also have the right to complain to us, or to the Secretary of the Federal 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 the privacy officer listed at the end of this Notice.

If you have any questions or if you wish to file a complaint or exercise any rights listed in this Notice, or to obtain the latest version of this Notice, please contact:

                        Folcroft Fire Company Ambulance Service

                        Attn: Privacy Officer

PO Box 65

Folcroft, PA 19032

Phone: 610-461-2256  extension 5

By signing this Privacy Notice, I understand my privacy rights concerning protected health information (PHI) about me and I agree to Authorization fully to the uses and disclosures of PHI by the Folcroft Fire Company Ambulance Service as outlined above.

Patient Signature: _________________________________            Date: ____________