CITY OF
ASHTABULA
DIVISION
OF FIRE
THIS
NOTICE DESCRIBES HOW
MEDICAL
INFORMATION ABOUT
YOU MAY
BE USED AND DISCLOSED
AND HOW
YOU MAY GAIN
ACCESS TO
THIS INFORMATION.
PLEASE
REVIEW IT CAREFULLY.
The City of Ashtabula, Division of Fire is required by law to
maintain the privacy of confidential health care information, known as
Protected Health Information or PHI, and to provide you with notice of our
legal duties and privacy practices with respect to your PHI. The City of Ashtabula, Division of Fire is
also required to abide by the terms of the version of this Notice currently in
effect.
Uses and Disclosures of
PHI: The City of Ashtabula, Division of Fire 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 be reimbursed for the services we provide to you,
including such things as submitting bills to insurance companies, making
necessary medical 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.
Use and Disclosure of
PHI Without Your Au-thorization. The
City of Ashtabula, Division of Fire 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 re quest 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 use of protected health
information for which you have already given 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. The City of Ashtabula, Division of
Fire is not required to agree to any restrictions you request, but any restrictions
agreed to by the City of Ashtabula, Division of Fire in writing are binding on
the City of Ashtabula, Division of Fire.
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
also request a papercopy of the Notice.
Revisions to the Notice: The City of Ashtabula, Division of Fire
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 website, 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:
Fire Chief, Privacy
Officer
City of Ashtabula
Division of Fire
4326 Main Avenue
(440) 992-7186 - Phone
(440) 992-2691 - Fax
Effective Date of the Notice:
June 1, 2009