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NOTICE OF PRIVACY PRACTICES
OF Gold Coast Ambulance
(the “Organization”)
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.
Your health information is personal, and we are committed to protecting it. Your
health information is also very important to our ability to provide you with
quality care, and to comply with certain laws. This Notice applies to all
records about your care that our personnel create. (Your physician may have a
different policies and a different notice regarding your health information that
is created in the physician’s office.) In addition, the hospital at which you
receive care may also have different policies and a different Notice regarding
your health information.
I. We Are Legally Required to Safeguard Your Protected Health Information. We
are required by law to:
A. maintain the privacy of your health information, also known as “protected
health information” or “PHI;”
B. provide you with this Notice, and
C. comply with this Notice
II. Future Changes to Our Practices and This Notice.
We reserve the right to change our privacy practices and to make any such change
applicable to the PHI we obtained about you before the change, as well as to
information we receive in the future. If a change in our practices is material,
we will revise this Notice to reflect the change. You may obtain a copy of any
revised Notice by contacting our Records Department at P.O. Box 7065, Oxnard, CA
93031. The Notice is also available in our business office or by calling (805)
485-3040.
III. How We May Use and Disclose Your Protected Health Information.
The law requires us to obtain your prior authorization for some uses and
disclosures. In other circumstances, the law allows us to use or disclose PHI
without your authorization. This Section III gives examples of each of these
circumstances.
A. Uses and Disclosures that do not Require Your Authorization. We may use or
disclose your PHI to provide treatment to you or in order for others to provide
treatment to you. For example, we may disclose your PHI to physicians, nurses,
and other health care personnel who are involved in your care.
We may also use or disclose your PHI to your insurance carrier in order to get
paid for treatment provided to you. For example, we may use your PHI to create
the bills that we submit to the insurance company, or we may disclose certain
portions of your PHI to our business associates who perform billing and claims
processing or other services for us. We may also disclose your PHI to another
health care provider or insurance company for their payment-related activities,
such as to get paid for treatment provided to you or to process claims under
your health insurance plan.
We may also use or disclose your PHI for our operations related to health care.
For example, we may use your PHI to evaluate the quality of care you received
from us, or to evaluate the performance of those involved with your care. We may
also provide your PHI to our attorneys, accountants and other consultants to
make sure we are complying with the laws that affect us. We may also provide
your contact information (such as name, address and phone number) and the dates
you received services from us, or to a foundation that helps us with our
fundraising efforts. In addition, we may also disclose your PHI to another
health care provider, health insurance plan or health care clearinghouse for
purposes of their operations related to health care. However, we will only do so
if they have or have had a relationship with you and if the PHI they request
pertains to that relationship. In addition, we will disclose your PHI to these
third parties for limited purposes only, such as for them to conduct quality
improvement activities, or to review the performance of a health care provider,
or for training purposes.
There are stricter requirements for use and disclosure for some types of PHI,
for example, drug and alcohol abuse patient information and HIV tests. However,
there are still limited circumstances in which these types of information may be
used or disclosed without your authorization.
B. Uses and Disclosures That Require Us to Give You the Opportunity to Object.
If you do not object, we may provide relevant portions of your PHI to a family
member, friend or other person you indicate is involved in your health care or
in helping you get insurance coverage or otherwise provide for payment for your
health care. We may use or disclose your PHI to notify your family or personal
representative of your location or condition. In an emergency or when you are
not capable of agreeing or objecting to these disclosures, we will disclose PHI
as we determine is in your best interest, but will give you the opportunity to
object to future disclosures to family and friends if possible. Unless you
object, we may also disclose your PHI to persons performing disaster relief
activities.
C. Certain Uses and Disclosures Do Not Require Your Authorization. The law
allows us to disclose PHI without your authorization in the following
circumstances:
(1) When Required by Law. We disclose PHI when we are required to do so by
federal, state or local law.
(2) For Public Health Activities. For example, we disclose PHI when we report
adverse reactions to a drug or medical device, or to notify a person who may
have been exposed to a disease in compliance with applicable law. We may also
report PHI to the local emergency medical services agency in connection with its
oversight role over ambulance services. We may also use and disclose your PHI as
necessary to comply with federal and state laws that govern workplace safety.
(3) For Reports about Victims of Abuse, Neglect or Domestic Violence. We will
disclose your PHI in these reports only if we are required or authorized by law
to do so, or if you otherwise agree.
(4) To Health Oversight Agencies. We will provide PHI as requested to government
agencies that have authority to audit or investigate our operations.
(5) For Lawsuits and Disputes. If you are involved in a lawsuit or dispute, we
may disclose your PHI in response to a court order or administrative order. We
may also disclose your PHI in response to a subpoena or other lawful process by
someone else involved in the dispute, but only if efforts have been made to tell
you about the request (which may include written notice to you) or to obtain a
court order that will protect the PHI requested.
(6) To Law Enforcement. We may release PHI as permitted by law if asked to do so
by a law enforcement official, in the following circumstances: (a) in response
to a court order issued by a court in the county where the records are located,
grand-jury subpoena, court-ordered warrant, administrative request or similar
process; (b) to identify or locate a suspect, fugitive, material witness or
missing person; (c) about the victim of a crime if, under certain limited
circumstances, we are unable to obtain the person’s agreement; (d) about a death
we believe may be due to criminal conduct; (e) about criminal conduct at our
facility; and (f) in emergency circumstances, to report a crime, its location or
victims, or the identity, description or location of the person who committed
the crime.
(7) To Coroners, Medical Examiners and Funeral Directors. We may disclose PHI to
facilitate the duties of these individuals.
(8) To Organ Procurement Organizations. We may disclose PHI to facilitate organ
donation and transplantation.
(9) To Avert a Serious Threat to Health or Safety. We may disclose your PHI to
someone who can help prevent a serious threat to your health and safety or the
health and safety of another person or the public.
(10) For Specialized Government Functions. For example, we may disclose your PHI
to authorized federal officials for intelligence and national security
activities that are authorized by law, or so that they may provide protective
services to the President or foreign heads of state or conduct special
investigations authorized by law.
(11) To Workers’ Compensation or Similar Programs. We may provide your PHI to
these programs in order for you to obtain benefits for work-related injuries or
illness.
(12) If you are an inmate of a correctional institution or under the custody of
a law enforcement official, we may release your PHI to the correctional
institution or law enforcement official as necessary for the institution to
provide you with health care, to protect your health or safety or that of others
or for the safety and security of the correctional institution.
IV. Other Uses and Disclosures of Your Protected Health Information.
Other uses and disclosures of your PHI that are not covered by this Notice or
the laws that apply to us will be made only with your written authorization. If
you give us written authorization for a use or disclosure of your PHI, you may
revoke that authorization, in writing, at any time. If you revoke your
authorization we will no longer use or disclosure your PHI for the purposes
specified in the written authorization, except that we are unable to take back
any disclosures we have already made with your permission. In addition, we can
use or disclose your PHI after you have revoked your authorization for actions
we have already taken in reliance on your authorization. We are also required to
retain certain records of the uses and disclosures made when the authorization
was in effect.
V. Your Rights Related to Your Protected Health Information.
You have the following rights:
A. The Right to Request Limits on Uses and Disclosures of Your PHI. You have the
right to ask us to limit how we use and disclose your PHI, as long as you are
not asking us to limit uses and disclosures that we are required or authorized
to make to the Secretary of the Department of Health and Human Services, related
to our facility’s patient directory, or the disclosures described in Section
III, above. Any such request must be submitted in writing to our Privacy
Officer. We are not required to agree to your request. If we do agree, we will
put it in writing and will abide by the agreement except when you require
emergency treatment.
B. The Right to Choose How We Communicate With You. You have the right to ask
that we send information to you at a specific address (for example, at work
rather than at home) or in a specific manner (for example, by e-mail rather than
by regular mail, or never by telephone). We must agree to your request as long
as it would not be disruptive to our operations to do so. You must make any such
request in writing, addressed to our Privacy Officer.
C. The Right to See and Copy Your PHI. Except for limited circumstances, you may
look at and copy your PHI that may be used to make decisions about your care if
you ask in writing to do so. Any such request must be addressed to our Records
Department. In certain situations we may deny your request, but if we do, we
will tell you in writing of the reasons for the denial and explain your rights
with regard to having the denial reviewed. If you ask us to copy your PHI, we
will charge you $0.50 for each page. Alternatively, we may provide you with a
summary or explanation of your PHI, as long as you agree to that and to the
cost, in advance.
D. The Right to Correct or Update Your PHI. If you believe that the PHI we have
about you is incomplete or incorrect, you may ask us to amend it. Any such
request must be made in writing you must tell us why you think the amendment is
appropriate. In addition, the following procedures apply:
We will not process your request if it is not in writing or does not tell us why
you think the amendment is appropriate. We will inform you in writing as to
whether the amendment will be made or denied. If we agree to make the amendment,
we will ask you who else you would like us to notify of the amendment. We may
deny your request if you ask us to amend information that:
(1) was not created by us, unless the person who created the information is no
longer available to make the amendment;
(2) is not part of the PHI we keep about you;
(3) is not part of the PHI that you would be allowed to see or copy; or
(4) is determined by us to be accurate and complete.
If we deny the requested amendment, we will tell you in writing how to submit a
statement of disagreement or complaint, or to request inclusion of your original
amendment request in your PHI.
Any request covered by this paragraph D. must be made in writing and must be
addressed to our Records Department.
E. The Right to Get a List of the Disclosures We Have Made. You have the right
to get a list of instances in which we have disclosed your PHI. The list will
not include certain disclosures, such as disclosures we have made for treatment,
payment and health care operations purposes, those that are a byproduct of
another use or disclosure permitted under our privacy policies or by law, those
made under an authorization provided by you, those made directly to you or your
family or friends or through our facility directory, or for disaster relief
purposes. Neither will the list include disclosures we have made for national
security purposes or to law enforcement personnel, or disclosures made before
April 14, 2003.
Your request for a list of disclosures must be made in writing and be addressed
to our Records Department. The list we provide will include disclosures made
within the last six years (except not for those made prior to April 14, 2003)
unless you specify a shorter period. The first list you request within a
12-month period will be free. You will be charged our reasonable costs for
providing any additional lists within the 12-month period.
F. The Right to Get a Paper Copy of This Notice. Even if you have agreed to
receive the Notice by e-mail, you have the right to request a paper copy as
well. You may obtain a paper copy of this Notice by contacting our Records
Department at P.O. Box 7065, Oxnard, CA 93031. The Notice is also available in
our business office or by calling (805) 485-3040.
VI. Complaints.
If you believe your privacy rights have been violated, you may file a complaint
with us or with the Secretary of the federal Department of Health and Human
Services. To file a complaint with us, put your compliant in writing and address
it to our Privacy Officer at P.O. Box 7065, Oxnard, CA 93031. We will not
retaliate against you for filing a complaint. You may also contact our Privacy
Officer if you have questions or comments about our privacy practices.
Effective Date: April 14, 2003.
Gold Coast Ambulance
625 N. A Street
P.O. Box 7065
Oxnard, CA 93031
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