Notice of Privacy Practices
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Allied
EMS Systems Inc.
Notice of Privacy Practices
Please review it carefully
If you have any questions about this Notice, please contact
David Slifka, Executive Director, at
1-800-533-7178
This Notice of Privacy Practices describes how Allied EMS Systems
Inc. may use and disclose your health information, and describes
your rights to access and control your health information. We
are required by law to maintain the privacy of your health information
and to provide you with this notice of our legal duties and privacy
practices with respect to your health information. We are
required to abide by the terms of the version of this notice currently
in effect. 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.
How We May Use and Disclose Your Health
Information
We may use and disclose your health information
to carry out treatment and related service for
you. For example, we may disclose your health information to an
Emergency Department that we transport you to for care, or we may
disclose your health information to other emergency care workers
who assist in the care render to you.
Your health information may be used, as needed, to obtain payment
for your health care services. For example, we may send billing
information to your insurance company, Medicare, or Medicaid.
We may use or disclose, as needed, your health information in order
to support our health care operation. These operations
include, but are not limited to, quality assessment activities,
licensing and training programs to ensure that our personnel meet
our standard of care and follow established policies and procedures,
obtaining legal and financial services, and creating reports that
do not individually identify you for data collection purposes.
Other Permitted Uses and Disclosures
Unless you object, we may disclose to a member of your family 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 it is in your best interest based upon our
professional judgment. We may use or disclose protected health information
to notify a family member, or any other person that is responsible
for your care, of your location, general condition, or death.
We may use or disclose your health information
to the extent required by law (for example, state
law requires certain reports); we may also disclose your health
information for public health activities, to a
health oversight agency for activities authorized
by law, such as audits of compliance of our office by government
authorities; in the course of judicial or administrative
proceedings (for example, in response to an order of a
court); compensation purposes; for national security and intelligence
activities; and to avert a serious and imminent threat to health
or safety of a person or the public. We may disclose your health
information to researchers to ensure the privacy of your health
information.
In some circumstances, Michigan state law may
be more stringent than federal law in restricting how we may use
or disclose your health information. In such situations, we will
comply with the law that is more protective of your health information
and/or that gives you additional rights.
Upon your request, we will give you the health information that
we maintain about you unless otherwise provided by law. We must
also make disclosures of your health information when required by
the federal Department of Health and Human Services to investigate
or determine our compliance with privacy laws.
Any other use or disclosure of your health information other than
as identified above will only be made with your written authorization,
unless otherwise permitted or required by law. 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.
Your Rights Regarding Your Health Information
You may inspect and obtain a copy of your health
information that is contained in our records. To do so, you must
submit a request for access in writing. We may charge a fee for
the costs of copying, mailing or other supplies and services associated
with your request. You have a right to your health information for
as long as we maintain records containing your health information.
In limited circumstances, we may deny your request to inspect and
obtain a copy of your health information; however, you may request
that our decision be reviewed.
You may request a restriction on how we use or
disclose your health information for the purposes of treatment,
payment or healthcare operations. You may also request that any
part of your health information not be disclosed to family members
or friends who may be involved in your care or for notification
purposes as described in this Notice of Privacy Practices. Your
written request must state the specific restriction requested and
to whom you want the restriction to apply. We are not required
to agree to a restriction that you may request. Any restriction
on information that Allied EMS Systems Inc. agrees to is binding
on Allied EMS Systems Inc. unless it is needed to provide emergency
treatment or we inform you that we are terminating our agreement
to your requested restriction.
You have the right to request to receive confidential communication
from us by alternative means or at an alternative location. For
example, you may request that we contact you by email or at work.
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. We will not request an explanation from you as to the
basis for the request. Please make sure this request is made in
writing.
If you believe that health information we have about you is incorrect
or incomplete, you may ask us to amend your health
information. Your request must be in writing and should state the
reason for the amendment and specific information to be amended.
In certain cases, we may deny your request for an amendment. If
we deny your request for amendment, you have the right to file a
statement of disagreement with us and we may prepare a rebuttal
to your statement, which we would provide to you.
You have the right to receive an accounting of
how we have disclosed your health information, other than for reasons
of treatment, payment, or our healthcare operations. This right
applies to disclosures made in the six years prior to the date of
your request, but after April 14, 2003. You may request an accounting
for a shorter timeframe. Your right to an accounting of disclosures
is subject to certain exceptions, restrictions, and limitations,
and excludes other disclosures, including those we may have made
to you, to family members or friends involved in your care or for
notification purposes, pursuant to your written authorization, and
incidental disclosures.
You have the right to obtain a paper copy of this Notice
from us, upon request, even if you have agreed to accept this notice
electronically.
Complaints
You may complain to us or to the Secretary of Health and Human Services
if you believe your privacy rights have been violated by us. You
may file a compliant with us by notifying our Privacy Contact of
your compliant. In no circumstances will we ever ask you to waive
your privacy rights granted under state or federal law, and we will
not retaliate against you for filing a compliant. You may contact
our Privacy Contacts:
David Slifka
Executive Director
Allied EMS Systems, Inc.
3407 M-119
Harbor Springs, MI 49740
(800) 533-7178
for further information about the complaint
process or if you have any other questions regarding your rights
and our privacy practices as described in this Notice.
This Notice was published and became effective on April 14th, 2003
Allied EMS Systems Inc.
On_________________ . Patient ________________________was
given notice of the Privacy Practices of Allied EMS Systems Inc.
by
ACKNOWLEDGEMENT OF RECEIPT OF PRIVACY NOTICE
I acknowledge that I was provided with a copy of Allied EMS Systems
Inc. Notice of Privacy Practices.
______________________________
Patient Signatures
______________________________
Date
Explanation of the good faith efforts that was made to provide
such Notice to the patient after the emergency treatment situation
was over.
______________________________________________________________________
______________________________________________________________________
______________________________
Name of Employee
______________________________
Date
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