Finger Lakes Ambulance EMS, Inc.
20 Crane St,
Clifton Springs, NY 14432
THIS NOTICE DESCRIBES HOW
YOUR MEDICAL INFORMATION
MAY BE USED AND DISCLOSED
AND HOW YOU CAN GET ACCESS TO
PLEASE REVIEW THIS NOTICE
Ambulance EMS, Inc. (the “Company”) is committed to maintaining the privacy of
your protected health information ("PHI"), which includes information
about your medical condition and the care and treatment you receive from the Company
and other health care providers. This Notice details how your PHI may be used
by the Company and disclosed to third parties for purposes of your care,
payment for your care, health care operations of the Company, and for other
purposes permitted or required by law. This Notice also details your rights
regarding your PHI.
USE OR DISCLOSURE OF PHI
The Company may use and/or
disclose your PHI for purposes related to your care, payment for your care, and
health care operations of the Company. The following are examples of the types
of uses and/or disclosures of your PHI that may occur. These examples are not
meant to include all possible types of use and/or disclosure.
Care – In order to provide ambulance services in an
emergency situation, the Company will provide your PHI to those health care
professionals directly involved in your care so that they may understand your
medical condition and needs, and provide advice or treatment (e.g., a
hospital). For example, the Company will provide the emergency room personnel
with an explanation about your condition.
Payment – In order to get paid for some or all of the services
provided by the Company, the Company may provide your PHI, directly or through
a billing service, to appropriate third party payors, pursuant to their billing
and payment requirements. For example, the Company may need to provide your
health insurance carrier or, if you are over 62, the Medicare program with
information about the ambulance services provided so that the Company can be properly
Health Care Operations – In order for the Company to operate in accordance
with applicable law, and in order for the Company to provide quality and
efficient care, it may be necessary for the Company to compile, use and/or
disclose your PHI. For example, the Company may use your PHI in order to
evaluate the performance of the Company's personnel in providing care to you.
The Company may use and/or
disclose your PHI, without a written Authorization from you, in the following
De-identified Information – Your PHI is altered so that it does not identify you
and, even without your name, cannot be used to identify you.
Business Associate – To a business associate, which is someone who the
Company contracts with to provide a service necessary for your treatment,
payment for your treatment and health care operations (e.g., billing
service). The Company will obtain satisfactory written assurance, in
accordance with applicable law, that the business associate will appropriately
safeguard your PHI.
Personal Representative – To a person who, under applicable law, has the
authority to represent you in making decisions related to your health care.
Public Health Activities - Such activities include, for example, information
collected by a public health authority, as authorized by law, to prevent or
control disease, injury or disability. This includes reports of child abuse or
Administration - If required by
the Food and Drug Administration to report adverse events, product defects or
problems or biological product deviations, or to track products, or to enable
product recalls, repairs or replacements, or to conduct post marketing
Abuse, Neglect or
Domestic Violence - To a
government authority if the Company is required by law to make such
disclosure. If the Company is authorized by law to make such a disclosure, it
will do so if it believes that the disclosure is necessary to prevent serious
harm or if the Company believes that you have been the victim of abuse, neglect
or domestic violence. Any such disclosure will be made in accordance with the
requirements of law, which may also involve notice to you of the disclosure.
Activities - Such activities,
which must be required by law, involve government agencies involved in
oversight activities that relate to the health care system, government benefit
programs, government regulatory programs and civil rights law. Those
activities include, for example, criminal investigations, audits, disciplinary
actions, or general oversight activities relating to the community's health
Administrative Proceeding - For
example, the Company may be required to disclose your PHI in response to a
court order or a lawfully issued subpoena.
Law Enforcement Purposes - In certain instances, your PHI may have to be
disclosed to a law enforcement official for law enforcement purposes. Law
enforcement purposes include: (1) complying with a legal process (i.e.,
subpoena) or as required by law; (2) information for identification and
location purposes (e.g., suspect or missing person); (3) information
regarding a person who is or is suspected to be a crime victim; (4) in
situations where the death of an individual may have resulted from criminal
conduct; (5) in the event of a crime occurring on the premises of the Company;
and (6) a medical emergency (not on the Company’s premises) has occurred, and
it appears that a crime has occurred.
Coroner or Medical
Examiner - The Company may
disclose your PHI to a coroner or medical examiner for the purpose of
identifying you or determining your cause of death, or to a funeral director as
permitted by law and as necessary to carry out its duties.
Organ, Eye or Tissue
Donation - If you are an organ
donor, the Company may disclose your PHI to the entity to whom you have agreed
to donate your organs.
Research - If the
Company is involved in research activities, your PHI may be used, but such use
is subject to numerous governmental requirements intended to protect the
privacy of your PHI such as approval of the research by an institutional review
board and the requirement that protocols must be followed.
Avert a Threat to Health
or Safety - The Company may
disclose your PHI if it believes that such disclosure is necessary to prevent
or lessen a serious and imminent threat to the health or safety of a person or
the public and the disclosure is to an individual who is reasonably able to
prevent or lessen the threat.
Specialized Government Functions - When the appropriate conditions apply, the Company
may use PHI of individuals who are Armed Forces personnel: (1) for activities
deemed necessary by appropriate military command authorities; (2) for the
purpose of a determination by the Company of Veteran Affairs of eligibility for
benefits; or (3) to a foreign military authority if you are a member of that
foreign military service. The Company may also disclose your PHI to authorized
federal officials for conducting national security and intelligence activities
including the provision of protective services to the President or others
Inmates - The Company may disclose your PHI to a correctional
institution or a law enforcement official if you are an inmate of that
correctional facility and your PHI is necessary to provide care and treatment
to you or is necessary for the health and safety of other individuals or
Workers' Compensation - If you are involved in a Workers' Compensation
claim, the Company may be required to disclose your PHI to an individual or
entity that is part of the Workers' Compensation system.
Disaster Relief Efforts – The Company may use or disclose your PHI to a public
or private entity authorized to assist in disaster relief efforts.
Required by Law - If otherwise required by law, but such use or
disclosure will be made in compliance with the law and limited to the
requirements of the law.
disclosures, other than those described above, will be made only with your
written Authorization, which you may revoke at any time.
The Company may, from time to
time, contact you to provide appointment reminders. The reminder may be in the
form of a letter or postcard. The Company will try to minimize the amount of
information contained in the reminder. The Company may also contact you by
phone and, if you are not available, the Company will leave a message for you.
The Company may, from time to time, contact you
about treatment alternatives, or other health benefits or services that may be
of interest to you.
The Company may
only use and/or disclose your PHI for marketing activities if we obtain from
you a prior written Authorization. "Marketing" activities include communications
to you that encourage you to purchase or use a product or service, and the
communication is not made for your care or treatment. However,
marketing does not include, for example, sending you a newsletter about this
Company. Marketing also includes the receipt by the Company of remuneration,
directly or indirectly, from a third party whose product or service is being
marketed to you. The Company will inform you if it engages in marketing and
will obtain your prior Authorization.
The Company may
use and/or disclose some of your PHI in order to contact you for fundraising
activities supportive of the Company. Any fundraising materials sent to you
will describe how you may opt out of receiving any further communications.
The Company may
disclose to your family member, other relative, a close personal friend, or any
other person identified by you, your PHI directly relevant to such person's
involvement with your care or the payment for your care. The Company may also
use or disclose your PHI to notify or assist in the notification (including
identifying or locating) a family member, a personal representative, or another
person responsible for your care, of your location, general condition or
death. However, in both cases, the following conditions will apply:
The Company may use or disclose
your PHI if you agree, or if the Company provides you with opportunity to
object and you do not object, or if the Company can reasonably infer from the
circumstances, based on the exercise of its judgment, that you do not object to
the use or disclosure.
If you are not present, the
Company will, in the exercise of its judgment, determine whether the use or
disclosure is in your best interests and, if so, disclose only the PHI that is
directly relevant to the person's involvement with your care.
You have the right to:
Revoke any Authorization, in
writing, at any time. To request a revocation, you must submit a written
request to the Company's Privacy Officer.
Request restrictions on certain
use and/or disclosure of your PHI as provided by law. However, the Company is
not obligated to agree to any requested restrictions. To request restrictions,
you must submit a written request to the Company's Privacy Officer. In your written
request, you must inform the Company of what information you want to limit,
whether you want to limit the Company’s use or disclosure, or both, and to whom
you want the limits to apply. If the Company agrees to your request, the
Company will comply with your request unless the information is needed in order
to provide you with emergency treatment.
communications of PHI by alternative means or at alternative locations. You
must make your request in writing to the Company's Privacy Officer. The
Company will accommodate all reasonable requests.
Inspect and copy your PHI as
provided by law. To inspect and copy your PHI, you must submit a notarized written
request to the Company's Privacy Officer. In certain situations that are defined
by law, the Company may deny your request, but you will have the right to have
the denial reviewed. The Company can charge you a fee for the cost of copying,
mailing or other supplies associated with your request.
Amend your PHI as provided by
law. To request an amendment, you must submit a notarized written request to
the Company's Privacy Officer. You must provide a reason that supports your
request. The Company may deny your request if it is not in writing, if you do
not provide a reason and support of your request, if the information to be
amended was not created by the Company (unless the individual or entity that
created the information is no longer available), if the information is not part
of your PHI maintained by the Company, if the information is not part of the
information you would be permitted to inspect and copy, and/or if the
information is accurate and complete. If you disagree with the Company’s
denial, you have the right to submit a written statement of disagreement.
Receive an accounting of
disclosures of your PHI as provided by law. To request an accounting, you must
submit a notarized written request to the Company's Privacy Officer. The
request must state a time period which may not be longer than six years and may
not include the dates before April 14, 2003. The request should indicate in
what form you want the list (such as a paper or electronic copy). The first
list you request within a 12 month period will be free, but the Company may
charge you for the cost of providing additional lists in that same 12 month
period. The Company will notify you of the costs involved and you can decide
to withdraw or modify your request before any costs are incurred.
Receive a paper copy of this
Privacy Notice from the Company upon request to the Company's Privacy Officer.
Complain to the Company, or to
the Secretary of Health and Human Services, Office of Civil Rights, Hubert H. Humphrey Building, 200 Independence Avenue, S. W., Room 509F HHH Building, Washington, D.C. 20201. Or you may contact a regional office of the Office of Civil
Rights, which can be found at www.hhs.gov/ocr/regmail.html. To file a
complaint with the Company, you must contact the Company's Privacy Officer.
All complaints must be in writing.
To obtain more information on,
or have your questions about your rights answered, you may contact the
Company's Privacy Officer, K. W. Kelly, at 315-462-5701 or via email at firstname.lastname@example.org.
Is required by law to maintain
the privacy of your PHI and to provide you with this Privacy Notice of the
Company's legal duties and privacy practices with respect to your PHI.
Is required to abide by the
terms of this Privacy Notice.
Reserves the right to change
the terms of this Privacy Notice and to make the new Privacy Notice provisions
effective for all of your PHI that it maintains.
Will not retaliate against you
for making a complaint.
Must make a good faith effort
to obtain from you an acknowledgement of receipt of this Notice, except in emergency
Will post this Privacy Notice
on the Company's web site, if the Company maintains a web site.
Will provide this Privacy
Notice to you by e-mail if you so request and the Company has the technology to
comply. However, you also have the right to obtain a paper copy of this
This Notice is
effective as of March 26, 2003.