TRI-STATE AMBULANCE, INC

NOTICE OF PRIVACY PRACTICES

Effective Date of Notice:  March 1, 2008

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.

Tri-State Ambulance, Inc. (“Tri-State”) is required by law to maintain the privacy of certain confidential health care information, known as Protected Health Information (PHI), and to provide you with a notice of our legal duties and privacy practices with respect to your PHI. Tri-State is also required by law to abide by the terms of the version of this Notice currently in effect.

How We May Use and Disclose PHI About You:

Tri-State 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 include:

·         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.

·         For Reminders of 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.

·         Business Associates.  We may share your health information with third party “business associates” that perform various activities for Tri-State Ambulance.  Whenever an arrangement with a business associate involves the use or disclosure of PHI, we will have a written contract containing terms that will protect the privacy of your health information.

·         Treatment Alternatives and Other Programs.  We may use or disclose your health information, as necessary, to provide you with information about treatment alternatives or other health-related programs, benefits and services that may be of interest to you.  We may also use your name and address to send you newsletters about the programs and services we offer. Further, we may use your name, address and health information to send you notices and invitations to celebration events offered by Tri-State Ambulance for patients who received certain care. We may also send you information about health-related products or services that we believe may be beneficial to you.  You may contact our Privacy Officer to request that these materials not be sent to you.

·         Fundraising Activities.  We may disclose information to a Tri-State Ambulance affiliate so that they may contact you in raising money for Tri-State Ambulance.  We only would disclose contact information, such as your name, address and phone number and the dates you received treatment or services by Tri-State Ambulance.  If you do not want Tri-State Ambulance to contact you for fundraising efforts, you may contact our Privacy Officer.

·         Others Involved in Your Care.   Unless you object, we may disclose to a member of your family, a relative, a close friend or any other person you identify, your health information that directly relates to that person’s involvement in your health care.  If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that is in your best interest based on our professional judgment.  We may use or disclose health information to notify or assist in notifying a family member, personal representative or any other person that is responsible for your care of your location, general condition or death.  Finally, we may use or disclose your health information to an authorized public or private entity to assist in disaster relief efforts and to coordinate uses and disclosures to family or other individuals involved in your care.

·         Research.  Under certain circumstances, we may use and disclose your health information for medical research purposes.  A special approval process is followed to protect your privacy.

Use and Disclosure of PHI Without Your Authorization:

·         As Required By Law.  We may use or disclose your health information to the extent that federal, state or local law requires the use or disclosure.  The use or disclosure will be made in compliance with the law and will be limited to the relevant requirements of the law. 

·         Criminal Activity.  Consistent with applicable federal and state laws, we may use or disclose your health information, if we believe that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public.  We may also disclose your health information if it is necessary for law enforcement authorities to identify or apprehend an individual.

·         Workers’ Compensation.  We may disclose your health information as authorized to comply with workers’ compensation laws and other similar legally established programs.

·         Public Health Risks.  We may disclose your health information for public health activities and purposes to a public health authority that is permitted by law to collect or receive that information.  These activities generally include child abuse or neglect, domestic violence, gunshot, knife wounds or other mandatory reportable incidents, persons exposed to disease or spreading or contracting a disease or condition.

·         Health Oversight Activities.  We may disclose your health information to a health oversight agency for activities authorized by law.  These oversight activities include, for example, audits, investigations, inspections, disciplinary proceedings, licensure and other administrative or judicial actions undertaken by the government (or their contractors) by law to oversee the health care system, government programs and compliance with civil rights laws.

·         Lawsuits and Disputes.  We may disclose your health information in response to a court or administrative order, discovery request, or another lawful process by someone else involved in the dispute.

·         Law Enforcement.  We may disclose your health information if asked to do so by a law enforcement official; for example, in the response to a court order, warrant, summons or similar process; to identify or locate a suspect, fugitive, material witness, or missing person.

Special Government Functions:

·         Military Activity and National Security.  When the appropriate conditions apply, we may use or disclose PHI of persons who are Armed Forces personnel for activities deemed necessary by appropriate military command authorities, for the determination by the Department of Veterans Affairs of your eligibility for benefits or foreign military authority. We may also disclose your PHI to authorized federal officials for conducting national security and intelligence.

·         Inmates.  If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may disclose your health information to the correctional institution or law enforcement official.  This disclosure would be necessary for the institution to provide you with health care; to protect your health and safety or the health and safety of others; or for the safety and security of the correctional institution.

·         Medical Suitability Determinations.  We may disclose your health information to the Department of State for use in making medical suitability determinations.

Other Uses and Disclosures of your PHI:

Other uses and disclosures of your PHI not covered by this notice or the laws that apply to Tri-State Ambulance will only be made with your written authorization.  You may revoke your authorization at any time, in writing.  You understand that we are unable to take back any disclosures we have already made with your authorization.

Your Rights Regarding PHI About You:

Although your health care record is the physical property of Tri-State Ambulance, the information belongs to you.  You have the following rights with respect to your PHI, including:

·         The Right to Access, Copy or Inspect Your PHI. You have the right to inspect and receive a copy of 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. If you wish to inspect and copy your medical information, you should contact our Privacy Officer.

·         The Right to Amend Your PHI. If you feel that the health information we have about you is incorrect or incomplete, you may ask us to amend that information. You have the right to request an amendment for as long as the information is kept by or for Tri-State Ambulance.   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 of Disclosures.  You have the right to request an “accounting of disclosures.”  This is a list of the disclosures we made containing your health information.  To request an accounting of disclosures, you must submit your request in writing to our Privacy Officer.  We must comply with your request for a list within 60 days, unless you agree to a 30-day extension.  We will not charge you a fee for the list, unless you request such list more than once per year. 

·         The Right to Request Restrictions of Your PHI. You have the right to request a restriction or limitation on the PHI we use or disclose about you for treatment, payment or health care operations.  You also have the right to request a limit on your PHI we disclose to someone who is involved in your care or for the payment of your care, like a family member or friend.  We are not required to agree with your request.  If we do agree, we will comply with your request unless the information is needed to provide emergency treatment.

·         The Right to Request Confidential Communications. We will accommodate reasonable requests.  We may also condition this accommodation by asking you for information as to how payment will be handled or specification of an alternative address or other method of contact.  For example, you can ask that we only contact you at home or only at work or only by mail.  We will not require an explanation from you for the basis of the request.  To request confidential communication, you must specify how or where you wish to be contacted.  Your request must be submitted to our Privacy Officer. 

Internet, Electronic Mail, and the Right to Obtain Copy of Paper Notice on Request:

Upon request, even if you have agreed to accept this Notice electronically you are still entitled to a paper copy.  You may print a copy of this Notice and future amendments to it by accessing the Tri-State Ambulance website, www.tristateambulance.org. 

Revisions to the Notice:

Tri-State 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. You can get a copy of the latest version of this Notice by contacting our Privacy Officer.

Your Legal Rights and Complaints:

If you believe your privacy rights have been violated, you may file a complaint with Tri-State Ambulance or with the Secretary of the United States Department of Health and Human Services.  To file a complaint with us, contact our Privacy Officer.  All complaints must be submitted in writing.  To file a complaint with the Secretary, please contact our Privacy Officer to obtain more information.  We will not retaliate against you for filing such a complaint.

Privacy Officer Contact Information:

Matt Zavadsky, Tri-State Ambulance, Inc.

221 Buchner Place, La Crosse, WI  54603

Phone:  608-782-2282       

FAX: 608-782-4522

Email:  MZavadsky@tristateambulance.org

Website:  www.tristateambulance.org