Notice of Privacy Practices of METRO Ambulance, Inc.
Effective April 1, 2003
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.
1 . Legal Requirements. METRO Ambulance is legally required to maintain the privacy of certain confidential information about your health (referred to in this Notice as "protected health information") and to provide you with this Notice of our legal duties and privacy practices with respect to protected health information. METRO Ambulance is required to abide by the terms of this Notice as long as it is in effect. METRO Ambulance reserves the right to amend this Notice and to make the amended provisions effective for all protected health information we maintain. Any changes to this Notice will be posted at our facilities. You may obtain a copy of the latest version of this Notice from the Privacy Officer identified below.
2. Use and Disclosures of protected health information. METRO Ambulance maintains your protected health information in a confidential manner in accordance with legal requirements. However, METRO Ambulance may use protected health information as necessary, without your consent, for the purposes of treatment, payment, and health care operations. Some examples are:
Treatment. This involves oral and written information we will obtain and share among health care providers involved in your care and transportation. For example, we will create a written record of the care and transportation you receive.
Payment. This involves our obtaining payment for the transportation and services we provide to you. For example, we will provide information about your transportation and care to insurance companies and entities and agencies involved in reimbursement and medical necessity or utilization review.
Health care operations. This involves our use of information about you to improve the quality of care. For example, we will use information about you for training, quality control, and licensure purposes. In addition, METRO Ambulance is permitted to use and disclose protected health care information without your written authorization, or opportunity to object, in these ways:
Any use or disclosure authorized or required by Federal, state, or local law.
To your parent or guardian, if you are a minor.
Any use or disclosure related to public health activities, as authorized or required by law.
Use or disclosure in connection with judicial or administrative proceedings, lawsuits, subpoenas and disputes, as authorized or required by law.
For law enforcement purposes, as authorized or required by law.
In health care fraud and abuse detection activities, as authorized or required by law.
For health oversight activities, investigations by a governmental entity or its contractor, and disciplinary or licensure proceedings, as authorized or required by law.
For military, national defense and security, or law enforcement purposes, as authorized or required by law.
To coroners, medical examiners, and funeral directors, as authorized or required by law.
To avert threats to health and safety, as authorized or required by law.
For research and organ donation purposes, as authorized or required by law.
Uses and disclosures that do not identify you.
3. Other uses of protected health information. We will use protected health information for other purposes, unless you ask for restrictions on a specific use or disclosure, for the following other purposes:
To provide you reminders of scheduled transportation.
To provide you information about the services we provide and the benefits that may be available to you.
To contact you to raise funds for our activities.
Any other use or disclosure of protected health information (besides those described in paragraphs 2 and 3) will occur only with your written authorization. If you give us such an authorization, you may revoke it in writing at any time. Once you revoke such authorization, no further use of disclosure by virtue of that revoked authorization will occur.
4. Your Rights. You have the following rights regarding your protected health information, provided you make a written request to exercise these rights to METRO Ambulance's privacy officer identified below:
Right to request restriction. You may request limitations on the information we use or disclose for health care treatment, payment, or operations, but we are not required to agree to your request. If we agree, we will comply with your request unless the information is needed to provide you with emergency treatment.
Right to confidential communications. You may request that we communicate with you in a certain manner or at a certain location, but you must specify how or where you wish to be contacted.
Right to inspect and copy. You have a right to inspect and copy most of the information we will maintain about you. We will normally provide access to information within 30 days and charge a reasonable fee for copying it. Under limited circumstances, we can deny your request for information. You may appeal certain denials.
Right to request amendment. If you believe that the information we have about you is incorrect or incomplete, you may request an amendment. We will generally amend your information within 60 days of receiving a written request specifying the specific amendment you request. We can deny your request only in certain situations. For example, if we believe the information you have asked us to amend is correct and therefore should not be amended.
Right to accounting of disclosure of protected health information. You may request an accounting of certain disclosures of your protected health information we have made in the six years prior to the date of the request, but not prior to April 14, 2003. We are not required to provide an accounting of disclosures or uses that occurred for treat-ment, payment, or health care operations or our sharing of information with our business associates.
Right to receive a copy of this Notice. You may request a paper copy of this Notice from our Privacy Officer at any time. If we maintain a web site, we will post a copy of our current Notice on our site.
5. Exercising your rights. To exercise any of the rights described in this Notice, contact our Privacy Officer listed below.
6. Complaints. If you believe that your privacy rights have been violated, you may file a complaint with METRO Ambulance or with the Secretary of the United States Department of Health and Human Services. You will not be penalized or retaliated against in any way for making a complaint to METRO Ambulance or the Department of Health and Human Services.
7. Contacting METRO Ambulance. You may contact METRO Ambulance's Privacy Officers, Tim DeLong at (210) 945-7585 or write them at 129 Commercial Place, Schertz, Texas 78154 to file a complaint, if you have questions about this Notice, if you wish to request restrictions on uses and disclosures for health care treatment, payment, or operations, or if you wish to exercise your rights described above.
I authorize any entity or person that possesses health care information about me to disclose that information to: (1) METRO Ambulance, its agents, employees, and representatives; (2) The Centers for Medicare and Medicaid Services and its employees, contractors, insurance carriers, agents, and representatives; (3) Any insurance companies or other payers, and their contractors, agents, employees, and representatives, to the extent such health care information is needed, required or requested for purposes of obtaining or determining the reimbursement to be paid to METRO Ambulance for my care and transportation by METRO Ambulance. This authorization is valid for a period of one year from the date it was signed. I understand that I may revoke this authorization at any time by giving written notice to Privacy Officer Tim DeLong at 129 Commercial Place, Schertz, Texas 78154. I understand that METRO Ambulance may not condition the provision of treatment to me on my completion of this authorization.