White Rose
Ambulance
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.
ARMAR, Inc., d.b.a.
White Rose
Ambulance (“White Rose
Ambulance”) 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. White Rose
Ambulance is also required to abide by the terms of the version of this Notice
currently in effect.
Uses and Disclosures of PHI: White
Rose Ambulance
may use PHI for the purposes of treatment, payment, and health care operations,
in most cases without your written permission.
Examples of our use 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 health care 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 health care 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.
Reminders for Scheduled
Transports and Information on Other Services. We may also contact you to provide you with a
reminder of any scheduled appointments for non-emergency ambulance and medical
transportation, or to provide information about other services we provide.
Use and Disclosure of PHI Without
Your Authorization. White Rose Ambulance 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 health care operations activities
of another health care provider who treats you;
· For health care 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 an 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 to report 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 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 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
workers’ compensation 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 an 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 on that authorization.
Patient Rights: 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 any 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 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. 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 health care operations, or when
we share your health information with our business associates, like our billing
company or a medical facility from/to which we have transported you. We are also not required to give you an
accounting of our uses of protected health information 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. White
Rose Ambulance
is not required to agree to any restrictions you request, but any restrictions
agreed to by White Rose Ambulance in writing are binding on White Rose
Ambulance.
Internet, Electronic Mail,
and the Right to Obtain Copy of Paper Notice on Request. If we maintain a web site,
we will prominently post a copy of this Notice on our web site. 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 to the Notice: White Rose Ambulance 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 protected health information that
we maintain. Any material changes to the
Notice will be promptly posted in our facilities and posted to our web site, 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:
Privacy Officer
White Rose Ambulance
York,
PA 17403-1224
Telephone:
717-848-4740
FAX: 717-848-4748
Website: www.whiteroseambulance.com
Effective Date of the Notice:
Form 279 Rev 04/14/2003