Seymour Ambulance Association, Inc.

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 describes your legal rights, advises you of our privacy practices and lets you know how Seymour Ambulance Association, Inc. is permitted to use and disclose PHI about you.

Uses and Disclosures of PHI: Seymour Ambulance Association, Inc. may use or disclose your PHI without your authorization, or without providing you with an opportunity to object, for the following purposes:

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 as well as providing the hospital with a copy of the written record we create in the course of providing you with treatment and transport.

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 Healthcare 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, obtaining legal and financial services, conducting business planning, processing grievances and complaints, creating reports that do not individually identify you for data collection purposes, fundraising, and certain marketing activities.

Use and Disclosure of PHI Without Your Authorization: Seymour 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 activities of another healthcare provider;
• To another healthcare provider or entity for the payment activities of the provider or entity that receives the information (such as your hospital or insurance company);
• To another healthcare provider (such as the hospital to which you are transported) for the healthcare operations activities of the entity that receives the information as long as the entity receiving the information has or has had a relationship with you and the PHI pertains to that relationship;
• For healthcare fraud and abuse detection or for activities related to compliance with the law;
• 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. We may also disclose health information to your family, relatives, or friends if we infer from the circumstances that you would not object. For example, we may assume that you agree to our disclosure of your personal health information to your spouse when your spouse has called the ambulance for you. In situations where you are incapable of objecting (because you are not present or due to your incapacity or medical emergency), we may, in our professional judgment, determine that a disclosure to your family member, relative, or friend is in your best interest. In that situation, we will disclose only health information relevant to that person’s involvement in your care. For example, we may inform the person who accompanied you in the ambulance that you have certain symptoms and we may give that person an update on your vital signs and treatment that is being administered by our ambulance crew;
• 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, neglect or domestic violence, to report adverse events such as product defects, 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 healthcare 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, 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; and
• For research projects, but this will be subject to strict oversight and approvals and health information will be released only when there is a minimal risk to your privacy and adequate safeguards are in place in accordance with the law.

Any other use or disclosure of PHI, other than those listed above will only be made with your written authorization. (the authorization must specifically identify the information we seek to use or disclose, as well as when and how we seek to use or disclose it). Specifically, we must obtain your written authorization before using or disclosing your: (a) psychotherapy notes, other than for the purpose of carrying out our own treatment, payment or health care operations purposes, (b) PHI for marketing when we receive payment to make a marketing communication; or (c) PHI when engaging in a sale of your PHI. 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: You have the right to inspect and copy most of the medical information that we collect and maintain about you. Requests for access to your PHI should be made in writing to our HIPAA Compliance Officer. 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. If you wish to inspect and copy your medical information, you should contact Kyle Kelley, our HIPAA Compliance Officer.

We will normally provide you with access to this information within 30 days of your written request. If we maintain your medical information in electronic format, then you have a right to obtain a copy of that information in an electronic format. In addition, if you request that we transmit a copy of your PHI directly to another person, we will do so provided your request is in writing, signed by you (or your representative), and you clearly identify the designated person and where to send the copy of your PHI.

We may also charge you a reasonable cost-based fee for providing you access to your PHI, subject to the limits of applicable state law.

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 disclosures of your medical information. If you wish to request an accounting of disclosures of your PHI that are subject to the accounting requirement, you should contact Kyle Kelley, our HIPAA Compliance Officer and make a request in writing. You have the right to receive an accounting of certain disclosures of your PHI made within six (6) years immediately preceding your request. But, we are not required to provide you with an accounting of disclosures of your PHI: (a) for purposes of treatment, payment, or healthcare operations; (b) for disclosures that you expressly authorized; (c) disclosures made to you, your family or friends, or (d) for disclosures made for law enforcement or certain other governmental purposes

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. Seymour Ambulance is not required to agree to any restrictions you request however, any restrictions agreed to by Seymour Ambulance in writing are binding on Seymour Ambulance. Further, you have the right to request that a claim for service not be submitted to a payor. Seymour Ambulance will honor this request as long as the individual pays the provider for services within 45 days of the date of service.

Breach of Individual PHI: If we discover that there has been a breach of your unsecured PHI, we will notify you about that breach by first-class mail dispatched to the most recent address that we have on file. If you prefer to be notified about breaches by electronic mail, please contact Kyle Kelley, our HIPAA Compliance Officer, to make Seymour Ambulance Association, Inc. aware of this preference and to provide a valid email address to send the electronic notice. You may withdraw your agreement to receive notice by email at any time by contacting Kyle Kelley.

Right to request confidential communications. You have the right to request that we send your PHI to an alternate location (e.g., somewhere other than your home address) or in a specific manner (e.g., by email rather than regular mail). However, we will only comply with reasonable requests when required by law to do so. If you wish to request that we communicate PHI to a specific location or in a specific format, you should contact Kyle Kelley, our HIPAA Compliance Officer and make a request in writing.

Internet, Electronic Mail and the Right to Obtain Copy of Paper Notice on Request: If we maintain a website, we will prominently post a copy of the notice on our website.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: Seymour 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 website, if we maintain one. You may obtain a copy 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.

For billing questions or to request a copy of the report link, please click here. https://www.quickmedclaims.com/