TOWN OF MONTGOMERY AMBULANCE CORPS NOTICE OF PRIVACY PRACTICES

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.

This Notice tells you about the ways in which Town of Montgomery Ambulance Corps (referred to collectively in this Notice as “we” or TOMAC) may use and disclose your protected health information and your rights concerning your protected health information. “Protected health information” is information about you, including demographic information, that can reasonably be used to identify you and that relates to your past, present or future physical or mental health or condition, the provision of health care to you or the payment for that care.

We are required by a federal law, called the Health Insurance Portability and Accountability Act of 1996 (referred to as HIPAA), to provide you with this Notice about your rights and our legal duties and privacy practices with respect to your protected health information. We must follow the terms of this Notice while it is in effect. It’s important to note that some of the uses and disclosures described in this Notice may be limited in certain cases by applicable state laws that are more stringent than the federal standards.

HOW WE MAY USE AND DISCLOSE YOUR PROTECTED HEALTH INFORMATION

We may use and disclose your protected health information for certain purposes, including for payment, health care operations and treatment, without first obtaining your authorization. Here are some examples of how TOMAC may use or disclose your protected health information without your authorization for payment, health care operations and treatment.

• “Payment” refers to the activities of TOMAC in collecting payment for health care services you receive. For example, we may use your protected health information for billing purposes or to be reimbursed by an insurer that may be responsible for payment.
• Health Care Operations.“Health Care Operations” refers to the basic business functions necessary to operate our ambulance service. For example, we may use your protected health information to review the quality of the care and services you receive.
• “Treatment” refers to the provision and coordination of health care by a doctor, hospital or other health care provider. For example, we may disclose your protected health information to your doctors to enable them to provide proper medical care to you.

OTHER PERMITTED OR REQUIRED DISCLOSURES

• As Required by Law. We must disclose protected health information about you when required to do so by law.
• Public Health Activities. We may disclose protected health information to public health agencies for reasons such as preventing or controlling disease, injury or disability.
• Victims of Abuse, Neglect or Domestic Violence. We may disclose protected health information about abuse, neglect or domestic violence to government agencies. We will make every effort to obtain your permission before releasing this information; however, in some cases, we may be required or authorized by law to act without your permission.
• Health Oversight Activities.We may disclose protected health information to government oversight agencies (e.g., U.S. Department of Labor) for activities authorized by law.
• Judicial and Administrative Proceedings.We may disclose protected health information in response to a court or administrative order. We may also disclose protected health information about you in certain cases in response to a subpoena, discovery request or other lawful process.
• Law Enforcement. We may disclose protected health information under limited circumstances to a law enforcement official in response to a warrant or similar process; to identify or locate a suspect; or to provide information about the victim of a crime.
• Coroners, Funeral Directors, Organ Donation. We may release protected health information to coroners or funeral directors as necessary to allow them to carry out their duties. We may also disclose protected health information in connection with organ or tissue donation.
• Under certain circumstances, we may disclose protected health information about you for research purposes, provided certain measures have been taken to protect your privacy.
• To Avert a Serious Threat to Health or Safety.We may disclose protected health information about you, with some limitations, when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person.
• Special Government Functions.We may disclose information as required by military authorities or to authorized federal officials for national security and intelligence activities.
• Workers’ Compensation.We may disclose protected health information to the extent necessary to comply with state law for workers’ compensation programs.

OTHER USES OR DISCLOSURES WITH AN AUTHORIZATION

Other uses or disclosures of your protected health information will be made only with your written authorization, unless otherwise permitted or required by law. You may revoke an authorization at any time, in writing, except to the extent that we have already taken action on the basis of the authorization. We may use or disclose protected health information to notify your family member, friends or personal representative about your condition. In an emergency or when you are not capable of agreeing or objecting to these disclosures, we will disclose your protected health information only to the extent we reasonably believe such disclosure to be in your best interest, and we will tell you about such disclosure after the emergency has passed, and give you the opportunity to object to future disclosures to family, friends or personal representatives. Unless you object, we may also disclosure your protected health information to persons involved in providing disaster relief, for example, the American Red Cross.

YOUR RIGHTS REGARDING YOUR PROTECTED HEALTH INFORMATION

You have certain rights regarding protected health information that TOMAC maintains about you. Any other use or disclosure of protected health information, other than those listed above will only be made with your written authorization. The law also requires your written authorization before we may use or disclose: (i) psychotherapy notes, other than for the purpose of carrying out our treatment, payment or health care operations purposes, (ii) any protected health information for our marketing purposes or (iii) any protected health information as part of a sale of protected health information. You may revoke a previous written authorization in writing at any time. If you elect to revoke a previously authorization, we will immediately stop any further uses or disclosures of your protected health information for the purposes set out in the written authorizations to the extent we have not already acted in reliance on your authorization; however, we will be unable to retract any disclosures previously made with your permission.

 

• Right To Access Your Protected Health Information.You have the right to review or obtain copies of your protected health information records, with some limited exceptions. Your request to review and/or obtain a copy of your protected health information records must be made in writing. We may charge a fee for the costs of producing, copying and mailing your requested information, but we will tell you the cost in advance.
• Right To Amend Your Protected Health Information. If you feel that protected health information maintained by TOMAC is incorrect or incomplete, you may request that we amend the information. Your request must be made in writing and must include the reason you are seeking a change. We may deny your request if, for example, you ask us to amend information that was not created by TOMAC or you ask to amend a record that is already accurate and complete.
  If we deny your request to amend, we will notify you in writing. You then have the right to submit to us a written statement of disagreement with our decision and we have the right to rebut that statement.
• Right to an Accounting of Disclosures by TOMAC.You have the right to request an accounting of disclosures we have made of your protected health information. The list will not include our disclosures made for treatment, payment or health care operations, or disclosures made to you or with your authorization. The list may also exclude certain other disclosures, such as for national security purposes.
  Your request for an accounting of disclosures must be made in writing and must state a time period for which you want an accounting. This time period may not be longer than six years and may not include dates before April 14, 2003. The first accounting that you request within a 12-month period will be free. For additional lists within the same time period, we may charge for providing the accounting, but we will tell you the cost in advance.
• Right To Request Restrictions on the Use and Disclosure of Your Protected Health Information.You have the right to request that we restrict or limit how we use or disclose your protected health information for treatment, payment or health care operations. We may not agree to your request. If we do agree, we will comply with your request unless the information is needed for an emergency. Your request for a restriction must be made in writing. In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit how we use or disclose your information, or both; and (3) to whom you want the restrictions to apply.
• Right To Receive Confidential Communications. You have the right to request that we use a certain method to communicate with you or that we send information to a certain location. Your request to receive confidential communications must be made in writing. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.
• Right to a Paper Copy of This Notice. You have a right at any time to request a paper copy of this Notice, even if you had previously agreed to receive an electronic copy.
• Contact Information for Exercising Your Rights.You may exercise any of the rights described above by contacting the TOMAC privacy officer at #.

 

NOTIFICATION IN THE EVENT OF AN UNAUTHORIZED USE OR DISCLOSURE

 

The law may require us to notify you in the event of an unauthorized use or disclosure of your unsecured protected health information. To the extent we are required to notify you, we must do so no later than 60 days following our discovery of such unauthorized use or disclosure. This notification will be made by first class mail or email (if you have indicated a preference to be notified by email), and must contain the following information:

• A description of the unauthorized use or disclosure, including the date of the unauthorized use or disclosure and the date of its discovery, if known.
• A description of the type of unsecured protected health information that was used or disclosed.
• A description of the steps you should take to protect yourself from potential harm resulting from the unauthorized use or disclosure.
• A brief description of what we are doing to investigate the breach, to protect against future breaches, and to mitigate the harm to you.
• A way to contact us to ask questions or obtain additional information.

CHANGES TO THIS NOTICE

We reserve the right to change the terms of this Notice at any time, effective for protected health information that we already have about you as well as any information that we receive in the future. We will communicate any changes to our notice through subscriber newsletters, direct mail, and/or our website.

COMPLAINTS

If you believe that your privacy rights have been violated, you may file a complaint with us and/or with the Secretary of the Department of Health and Human Services. To file a complaint with the DHHS, you must put your complaint in writing and mail it to: Office for Civil Rights, U.S. Department of Health and Human Services, Jacob Javits Federal Building, 26 Federal Plaza, Suite 3312, New York, NY 10278. All complaints to TOMAC should be directed to customer service at the phone number printed on your identification card.

We support your right to protect the privacy of your protected health information. We will not retaliate against you or penalize you for filing a complaint.