NOTICE OF PRIVACY PRACTICES FOR PROTECTED HEALTH INFORMATION (PHI)
This Notice of Privacy Practices describes how Taylor Emergency Medical Services may use and disclose your “protected health information” (PHI) to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law. It also describes your rights to access and control of your protected health information. Protected health information is information about you including demographic information that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services.
We are required to abide by the terms of this Notice of Privacy Practices. We may change the terms of our notice at any time. The new notice will be effective for all protected health information that we maintain both before and after the change. Upon your request, we will provide you with any revised Notice of Privacy Practices by calling the department and requesting that a revised copy be sent to you in the mail.
1. Uses and Disclosures of Protected Health Information
You will be asked to sign a Notice of Privacy Practice or similarly worded statement related to disclosure of Protected Health Information. We will make a good faith effort to obtain a written acknowledgement that you received this Notice of Privacy Practices for Protected Health Information the first time we provide services to you or as soon as reasonably practicable under the circumstances. Your protected health information may be used and disclosed by Taylor Snowflake Fire & Medical Department (TSFMD), our department staff, and others outside of our department that are involved in your care and treatment for the purpose of providing health care services to you. Your protected health information may also be used and disclosed to obtain payment for your health care bills.
Following are examples of the types of uses and disclosures of your protected health care information that TSFMD is permitted to make. These examples are not meant to be exhaustive, but to describe the typical uses and disclosures that may be made by our department.
· Treatment: We will use and disclose your protected health information to provide, coordinate or manage your health care and any related services. This includes the coordination or management of your health care with a third party that may need access to your protected health information. For example, your protected health information may be provided to another emergency medical services agency that becomes involved in your care to ensure it has the necessary information to properly treat you. We will also disclose protected health information to hospital staff and physicians who may be treating you.
· Payment: Your protected health information will be used, as needed, to obtain payment for your health care services. This may include certain activities that your health insurance plan may undertake before it approves or pays for the health care services we recommend for you such as: making a determination of eligibility or coverage for insurance benefits, reviewing services provided to you for medical necessity and undertaking utilization review activities.
· Healthcare Operations: We may use or disclose, as needed, your protected health information in order to support the business activities of TSFMD. These activities include, but are not limited to, quality assessment activities, employee review activities, training of EMT students, licensing, and conducting or arranging for other business activities. We will share your protected health information with third party “business associates” that perform various activities (e.g., billing services) for the department. Whenever an arrangement between our department and a business associate involves the use of disclosure of your protected health information, we will have a written contract that contains terms that will protect the privacy of your protected health information.
Other Uses and Disclosures of Protected Health Information
Other uses and disclosures of your protected health information will be made only with your written authorization, unless otherwise permitted or required by law as described below. You may revoke this authorization at any time, in writing, except to the extent that TSFMD has taken an action in reliance on the use or disclosure indicated in the authorization.
Other Permitted and Required Uses and Disclosures
We may use and disclose your protected health information in the following instances. You have the opportunity to agree or object to the use or disclosure of all or part of your protected health information. If you are not present or able to agree or object to the use or disclosure of the protected health information, then TSFMD may, using professional judgment, determine whether the disclosure is in your best interest. In this case, only the protected health information that is relevant to your health care will be disclosed.
· Others Involved In Your Healthcare: Unless you object, we may disclose to a member of your family, a relative, a close friend or any other person you identify, your protected health information that directly related to that person’s involvement in your healthcare. If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgment. We may use or disclose protected health information to notify or assist in notifying a family member, personal representative or any other person that is responsible for your care of your location, general condition, or death. Finally, we may use or disclose your protected health information to an authorized public or private entity to assist in disaster relief efforts and to coordinate uses and disclosures to family or other individuals involved in your health care.
· Emergencies: We may use or disclose your protected health information in an emergency treatment situation. If this happens, TSFMD shall try to obtain your acknowledgement of our Privacy Practices as soon as reasonably practical after delivery of treatment. If TSFMD is required by law to treat you and TSFMD has attempted to obtain your acknowledgement but is unable to do so, TSFMD may still use or disclose your protected health information for treatment, payment, and health care options.
· Communication Barriers: We may use and disclose your protected health information if attempts to obtain an acknowledgement of our Privacy Practices is made but impossible due to substantial communication barriers.
Other Permitted and Required Uses and Disclosures that may be made without Your Consent, Authorization or
Opportunity to Object
We may use or disclose your protected health information in the following situations without your acknowledgement or authorization. These situations include:
· Required by Law
· Legal Proceedings
· Public Health
· Law Enforcement
· Communicable Diseases
· Coroners, Funeral Directors
· Health Oversight
· Organ Donation
· Abuse or Neglect
· Food and Drug Administration
· Criminal Activity
· Military Activity
· Workers’ Compensation
· National Security
· Required Uses and Disclosures
· Health Forms
2. Your Rights
The following is a statement of your rights with respect to your protected health information and a brief description of how you may exercise these tights.
You have the right to inspect and copy your protected health information. This means you may inspect and obtain a copy of protected health information about you that is contained in a designated record set for as long as we maintain that protected health information. A “designated record set” contains medical and billing records and any other records that TSFMD uses for making decisions about you. Applicable fees for copies and administrative research costs may be assessed.
Under federal law, however; you may not inspect or copy the following records: psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding: and protected health information that is subject to law that prohibits access to protected health information. Depending on the circumstances, a decision to deny access may be review-able. In some circumstances, you may have a right to have this decision reviewed. Please contact our privacy officer if you have questions about access to your medical record.
You have the right to request a restriction of your protected health information. This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or healthcare operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in the Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply
TSFMD is not required to agree to a restriction that you may request. If TSFMD believes it is in your best interest to permit use and disclosure of your protected health information, your protected health information will not be restricted. If TSFMD does agree to the requested restriction, we may not use or disclose your protected health information in violation of that restriction unless it is needed to provide emergency treatment. With this in mind, please discuss any restriction you wish to request with TSFMD. You may request a restriction by submitting a written request to our privacy officer.
You have the right to request to receive confidential communications from us by alternative means or at an alternative location. We will accommodate reasonable requests. We may also condition this accommodation by asking you for information as to how payment will be handled or specification of an alternative address or other method of contact. We will not request an explanation from you as to the basis for the request. Please make this request in writing to our privacy officer.
You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information. This right applies to disclosures for purposes other than treatment, payment or healthcare operations and valid authorizations of incidental disclosures as described in this Notice of Privacy Practices. It excludes disclosures we may have made to you, to family members or friends involved in your care, or for notification purposes. You have the right to receive specific information regarding these disclosures that occurred after. You may request a shorter timeframe. The right to receive this information is subject to certain exceptions, restrictions and limitations
You have the right to obtain a paper copy of this notice from us, upon request.
You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our privacy officer of your complaint.
The privacy officer of TSFMD is the Director of the EMS Department. You may contact that individual at 928-536-7900 for further information about the complaint process.
TSFMD Ambulance Billing Agreement:
“By signing this at this time, I authorize the submission of a claim to Medicare, Medicaid, or any other payer for any services provided to me by Taylor Snowflake Fire & Medical Department (TSFMD) now, in the past, or in the future, until I revoke this authorization in writing. I understand I am financially responsible for services provided to me by [TSFMD], regardless of my insurance coverage, and may be responsible for an amount in addition to that which was paid by my insurance. I agree to immediately remit to [TSFMD] any payments that I receive directly from insurance or any source for the services provided to me and I assign all rights to such payments to [TSFMD]. I authorize [TSFMD] to appeal payment denials or other adverse decisions on my behalf. I authorize and direct any holder of medical, insurance, billing or other relevant information about me to release such information to [TSFMD] and its billing agents, the Centers for Medicare and Medicaid Services, and/or any other payers or insurers, and their respective agents or contractors, as may be necessary to determine these or other benefits payable for services provided to me by [TSFMD], now, in the past, or in the future. I also authorize [TSFMD] to obtain medical, insurance, billing and other relevant information about me from any party, database or other source that maintains such information. I also authorize [TSFMD] to verify my employment and agree to pay any and all collection costs, attorney costs, and late/interest fees. I permit a copy of this agreement to be used in place of the original.
I acknowledged I have been informed that I can obtain a copy of this billing agreement and the privacy statement online at www.taylorsnowflakefire.org”
This notice was updated on 9-28-16