Decatur Township Fire Department

Employee Section

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Decatur Township Fire Department

Notice of Privacy Practices

IMPORTANT: 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.

As an essential part of our commitment to you, Decatur Township Fire Department maintains the privacy of certain confidential health care information about you, known as Protected Health Information or PHI. We are required by law to protect your health care information and to provide you with the attached Notice of Privacy Practices.

The Notice outlines our legal duties and privacy practices respect to your PHI. It not only describes our privacy practices and your legal rights, but lets you know, among other things, how Decatur Township Fire Department is permitted to use and disclose PHI about you, how you can access and copy that information, how you may request amendment of that information, and how you may request restrictions on our use and disclosure of your PHI.

Decatur Township Fire Department is also required to abide by the terms of the version of this Notice currently in effect. In most situations we may use this information as described in this Notice without your permission, but there are some situations where we may use it only after we obtain your written authorization, if we are required by law to do so.

We respect your privacy, and treat all health care information about our patients with care under strict policies of confidentiality that all of our staff is committed to following at all times.

PLEASE READ THE ATTACHED DETAILED NOTICE. IF YOU HAVE ANY QUESTIONS ABOUT IT, PLEASE CONTACT Mary Ann Hibler, OUR PRIVACY OFFICER, AT 317-856-5400.

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.

Purpose of this Notice: Decatur Township Fire Department is required by law to maintain the privacy of certain confidential health care information, known as Protected Health Information or PHI, and to provide you with a notice of our legal duties and privacy practices with respect to your PHI. This Notice describes your legal rights, advises you of our privacy practices, and lets you know how Decatur Township Fire Department is permitted to use and disclose PHI about you.

Uses and Disclosures of PHI: Decatur Township Fire Department 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:

For treatment. This includes such things as verbal and written information that we obtain about you and use pertaining to your medical condition and treatment provided to you by us and other medical personnel (including doctors and nurses who give orders to allow us to provide treatment to you). It also includes information we give to other health care personnel to whom we transfer your care and treatment, and includes transfer of 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 organizing your PHI and submitting bills to insurance companies, management of billed claims for services rendered, medical necessity determinations and reviews, utilization review, and collection of 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, 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. Decatur Township Fire Department is permitted to use PHI without your written authorization, or opportunity to object in certain situations, including:

· For Decatur Township Fire Department’s use in treating you or in obtaining payment for services provided to you or in other health care operations;

· For the treatment activities of another health care provider;

· To another health care 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 health care provider (such as the hospital to which you are transported) for the health care 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 health care 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 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 not capable 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 or 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 health care 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;

· 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;

· We may use or disclose health information about you in a way that does not personally identify you or reveal who you are.

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). 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 the protection of your PHI, including:

The right to access, copy or inspect your PHI. This means you may come to our offices and inspect and copy 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 the privacy officer listed at the end of this Notice.

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 the privacy officer listed at the end of this Notice.

The right to request an accounting of our use and disclosure of your PHI. You may request an accounting from us of certain disclosures of your medical information that we have made in the last six years prior to the date of your request. We are not required to give you an accounting of information we have used or disclosed for purposes of treatment, payment or health care operations, or when we share your health information with our business associates, like our billing Fire Department or a medical facility from/to which we have transported you.

We are also not required to give you an accounting of our uses of protected health information for which you have already given us written authorization. If you wish to request an accounting of the medical information about you that we have used or disclosed that is not exempted from the accounting requirement, you should contact the privacy officer listed at the end of this Notice.

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 for treatment, payment or health care operations, or to restrict the information that is provided to family, friends and other individuals involved in your health care. But if you request a restriction and the information you asked us to restrict is needed to provide you with emergency treatment, then we may use the PHI or disclose the PHI to a health care provider to provide you with emergency treatment. Decatur Township Fire Department is not required to agree to any restrictions you request, but any restrictions agreed to by Decatur Township Fire Department are binding on Decatur Township Fire Department.

Internet, Electronic Mail, and the Right to Obtain Copy of Paper Notice on Request. This notice is posted at www.decaturfire.org and is available electronically through the web site. 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: Decatur Township Fire Department 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 web site (www.decaturfire,org). You can get a copy of the latest version of this Notice by contacting the Privacy Officer identified below.

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 the privacy officer listed at the end of this Notice. Individuals will not be retaliated against for filing a complaint.

If you have any questions or if you wish to file a complaint or exercise any rights listed in this Notice, please contact:

Mary Ann Hibler (Privacy Officer)

Decatur Township Fire Department

5410 S High School Road

Indianapolis, IN 46221

317-856-5400

Effective April 10, 2003

BILLING AUTHORIZATION, RESPONSIBILITY FOR PAYMENT

AND RECEIPT OF NOTICE OF PRIVACY RIGHTS

I understand that I am financially responsible for the services provided to me by Decatur Township Fire Department (“DTFD”) regardless of insurance coverage. I request that payment of authorized Medicare or other insurance benefits be made on my behalf to DTFD for any services provided to me by DTFD. I authorize and direct any holder of medical information or documentation about me to release to the Centers for Medicare and Medicaid Services and its carriers and agents, as well as to DTFD and its billing agents and any other payers or insurers, any information or documentation needed to determine these benefits or benefits payable for any services provided to me by DTFD, now or in the future. I agree to immediately remit to DTFD any payments that I receive directly from any source for the services provided to me and I assign all rights to such payments to Decatur Township Fire Department.

I also acknowledge that I have received a copy of the Decatur Township Fire Department Notice of Privacy Practices. A copy of this form is as valid as the original.

_____________________________________________ Date:_________________

Patient Signature

_____________________________________________ _______________________

Patient Representative’s Signature Relationship to Patient

Patient unable to sign because:

________________________________________________________________________

Decatur Township Fire Department

Policy on Patient Access, Amendment and Restriction on Use of Protected Health Information

Purpose

Under the HIPAA Privacy Rule, individuals have the right to access and to request amendment or restriction on the use of their protected health information, or PHI, and restrictions on its use that is maintained in “designated record sets,” or DRS. (See policy on Designated Record Sets).

To ensure that Decatur Township Fire Department only releases the PHI that is covered under the Privacy Rule, this policy outlines procedures for requests for patient access, amendment, and restriction on the use of PHI.

This policy also establishes the procedure by which patients or appropriate requestors may access PHI, request amendment to PHI, and request a restriction on the use of PHI.

Policy

Only information contained in the DRS outlined in this policy is to be provided to patients who request access, amendment and restriction on the use of their PHI in accordance with the Privacy Rule and the Privacy Practices of Decatur Township Fire Department.

Procedure

Patient Access:

1. Upon presentation to the business office, the patient or appropriate representative will complete a Request for Access Form.

2. The Fire Department employee must verify the patient’s identity, and if the requestor is not the patient, the name of the individual and reason that the request is being made by this individual. The use of a driver’s license, social security card, or other form of government-issued identification is acceptable for this purpose.

3. The completed form will be presented to the Privacy Officer for action.

4. The Privacy Officer will act upon the request within 30 days.

5. If the Fire Department is unable to respond to the request within these time frames, the requestor must be given a written notice no later than the initial due date for a response, explaining why the Fire Department could not respond within the time frame and in that case the Fire Department may extend the response time by an additional 30 days.

6. Upon approval of access, patient will have the right to access the PHI contained in the DRS outlined below and may make a copy of the PHI contained in the DRS upon verbal or written request.

7. The business office has established a reasonable charge of $5.00 for copying PHI for the patient or appropriate representative.

8. Patient access may be denied for the reasons listed below, and in some cases the denial of access may be appealed to the Fire Department for review.

9. The following are reasons to deny access to PHI that are not subject to review and are final and may not be appealed by the patient:

a. If the information the patient requested was compiled in reasonable anticipation of, or use in, a civil, criminal or administrative action or proceeding;

b. If the information the patient requested was obtained from someone other than a health care provider under a promise of confidentiality and the access requested would be reasonably likely to reveal the source of the information.

10. The following reasons to deny access to PHI are subject to review and the patient may appeal the denial:

a. If a licensed health care professional has determined, in the exercise of professional judgment, that the access requested is reasonably likely to endanger the life or physical safety of the individual or another person;

b. If the protected health information makes reference to another person (other than a health care provider) and a licensed health professional has determined, in the exercise of professional judgment, that the access requested is reasonably likely to cause substantial harm to that person;

c. If the request for access is made by a requestor as a personal representative of the individual about whom the requestor is requesting the information, and a licensed health professional has determined, in the exercise of professional judgment, that access by you is reasonably likely to cause harm to the individual or another person.

d. If the denial of the request for access to PHI is for reasons a, b, or c, then the patient may request a review of the denial of access by sending a written request to the Privacy Officer.

e. The Fire Department will designate a licensed health professional, who was not directly involved in the denial, to review the decision to deny the patient access. The Fire Department will promptly refer the request to this designated review official. The review official will determine within a reasonable period of time whether the denial is appropriate. The Fire Department will provide the patient with written notice of the determination of the designated reviewing official.

f. The patient may also file a complaint in accordance with the Procedure for Filing Complaints about Privacy Practices if the patient is not satisfied with the Fire Department’s determination.

11. Access to the actual files or computers that contain the DRS that may be accessed by the patient or requestor should not be permitted. Rather, copies of the records should be provided for the patient or requestor to view in a confidential area under the direct supervision of a designated Fire Department staff member. UNDER NO CIRCUMSTANCES SHOULD ORIGINALS OF PHI LEAVE THE PREMISES.

12. If the patient or requestor would like to retain copies of the DRS provided, then the Fire Department will charge $5.00 for the cots of reproduction.

13. Whenever a patient or requestor accesses a DRS, a note should be maintained in a log book indicating the time and date of the request, the date access was provided, what specific records were provided for review, and what copies were left with the patient or requestor.

14. Following a request for access to PHI, a patient or requestor may request an amendment to his or her PHI, and request restriction on its use in some circumstances.

Requests for Amendment to PHI

15. The patient or appropriate requestor may only request amendment to PHI contained in the DRS. The “Request for Amendment of PHI” Form must be accompanied with any request for amendment.

16. The Fire Department must act upon a Request for Amendment within 60 days of the request. If the Fire Department is unable to act upon the request within 60 days, it must provide the requestor with a written statement of the reasons for the delay, and in that case may extend the time period in which to comply by an additional 30 days.

Granting Requests for Amendment

17. All requests for amendment must be forwarded immediately to the Privacy Officer for review.

18. If the Privacy Officer grants the request for amendment, then the requestor will receive a letter indicating that the appropriate amendment to the PHI or record that was the subject of the request has been made.

19. There must be written permission provided by the patient so that that the Fire Department may notify the persons with which the amendments need to be shared. The Fire Department must provide the amended information to those individuals identified by having received the PHI that has been amended as well as those persons or business associates that have such information and who may have relied on or could be reasonably expected to rely on the amended PHI.

20. The patient must identify individuals who may need the amended PHI and sign the statement in the Request for Amendment form giving the Fire Department permission to provide them with the updated PHI.

21. The Fire Department will add the request for amendment, the denial or granting of the request, as well as any statement of disagreement by the patient and any rebuttal statement by the Fire Department to the designated record set.

Denial of Requests for Amendment

22. The Fire Department may deny a request to amend PHI for the following reasons: 1) If the Fire Department did not create the PHI at issue; 2) if the information is not part of the DRS; or 3) the information is accurate and complete.

23. The Fire Department must provide a written denial, and the denial must be written in plain language and state the reason for the denial; the individual’s right to submit a statement disagreeing with the denial and how the individual may file such a statement; a statement that, if the individual does not submit a statement of disagreement, the individual may request that the provider provide the request for amendment and the denial with any future disclosures of the PHI; and a description of how the individual may file a complaint with the covered entity, including the name and telephone number of an appropriate contact person, or to the Secretary of Health and Human Services.

24. If the individual submits a “statement of disagreement,” the provider may prepare a written rebuttal statement to the patient’s statement of disagreement. The statement of disagreement will be appended to the PHI, or at the Fire Department’s option, a summary of the disagreement will be appended, along with the rebuttal statement of the Fire Department.

25. If the Fire Department receives a notice from another covered entity, such as a hospital, that it has amended its own PHI in relation to a particular patient, the ambulance service must amend its own PHI that may be affected by the amendments.

Requests for Restriction

26. The patient may request a restriction on the use and disclosure of their PHI.

27. The Fire Department is not required to agree to any restriction, and given the emergent nature of our operation, we generally will not agree to a restriction.

28. ALL REQUESTS FOR RESTRICTION ON USE AND DISCLOSURE OF PHI MUST BE SUBMITTED IN WRITING ON THE APPROVED FIRE DEPARTMENT FORM. ALL REQUESTS WILL BE REVIEWED AND DENIED OR APPROVED BY THE PRIVACY OFFICER.

29. If the Fire Department agrees to a restriction, we may not use or disclosed PHI in violation of the agreed upon restriction, except that if the individual who requested the restriction is in need of emergency service, and the restricted PHI is needed to provide the emergency service, the Fire Department may use the restricted PHI or may disclose such PHI to another health care provider to provide treatment to the individual.

30. The agreement to restrict PHI will be documented to ensure that the restriction is followed.

31. A restriction may be terminated if the individual agrees to or requests the termination. Oral agreements to terminate restrictions must be documented. A current restriction may also be terminated by the Fire Department as long as the Fire Department notifies the patient that PHI created or received after the restriction is removed is no longer restriction. PHI that was restricted prior to the Fire Department voiding the restriction must continue to be treated as restricted PHI.