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NOTICE OF PRIVACY PRACTICES

BELLBROOK FIRE/EMS DEPARTMENT

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.

If you have any questions about this notice, please contact EMS Officer, Captain Athena Haus, our privacy contact.

This Notice of Privacy Practices describes how we may use and disclose your protected health information to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. Protected health information means health information, including demographic information, collected from me and created or received by my physician, another health care provider, health plan, my employer or a health care clearinghouse. This protected health information relates to my past, present or future physical or mental health or condition and identifies me, or there is a reasonable basis to believe the information may identify me.

We are required to abide by the terms of this Notice of Privacy Practices. We may change the terms of our notice, at any time. The new notice will be effective for all protected health information that we may obtain at that time. Upon your request, we will provide you with any revised notice of privacy practices by calling the office and requesting that a revised copy be sent to you in the mail.

1. Uses and Disclosures of Protected Health Information Based Upon your Written Consent.

The Bellbrook Fire/EMS Department will use or disclose protected health information for the following purposes:

Treatment.We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. For example, we would disclose your protected health information, as necessary, to your physician or to the Emergency Department who is treating you. We will also disclose protected health information to other physicians who may be treating you. For example, your protected health information may be provided to a physician to whom you have been referred.

Payment.Your protected health information will be used to obtain payment for your health care services. This may include certain activities that your health insurance plan may undertake before it approves or pays for your health care services, such as making a determination of eligibility or coverage for insurance benefits, reviewing services provided to you for medical necessity, and undertaking utilization review activities.

Health Care Operations.We may use or disclose your protected health information in order to support the business activities of the Fire Department. These activities include, but are not limited to, the day-to-day running of the Department, quality assessments, employee reviews, training of medical students, licensing, marketing, and fundraising, and conducting or arranging for other business activities.

For example, we may disclose your protected health information to medical students who are preceptors from approved programs.

We will share your protected health information with third party "business associates" that perform various activities (e.g., billing, transcription services) for the Fire Department. Whenever an arrangement between the Fire Department and a business associate involves the use or disclosure of your protected health information, we will have a written contract that contains terms that will protect the privacy of your protected health information.

We may use or disclose your protected health information to provide you with information about treatment, alternatives or other health-related benefits and services that may be of interest to you. We may also use and disclose your protected health information for other marketing activities. For example, your name and address may be used to send you a newsletter about the services we offer. We may also send you information about products and services that we believe may be beneficial to you. You may contact our privacy contact to request that these materials not be sent to you.

We may use or disclose your demographic information and the dates that you received treatment, as necessary, in order to contact you for fundraising activities supported by our office. If you do not want to receive these materials, please contact our privacy contact and request that these fundraising materials then be sent to you.

2. Uses and Disclosures of Protected Health Information Based Upon your Written Authorization.

Other uses and disclosures of your protected health information will be made only with your written authorization, unless otherwise permitted or required by law as described below. You may revoke this authorization, at any time, in writing, except to the extent that the Fire Department has taken an action in reliance on the use or disclosure indicated in the authorization.

3. Other Permitted and Required Uses and Disclosures that may be made with your Consent, Authorization, or Opportunity to Object.

We may use and disclose your protected health information in the following instances. You have the opportunity to agree or object to the use or disclosure of all or part of your protected health information. If you are not present or able to agree or object to the use or disclosure of the protected health information, then the Fire Division may, using professional judgment, determine whether the disclosure is in your best interest. In this case, only the protected health information that is relevant to your health care will be disclosed.

4. Other Permitted and Required Uses and Disclosures that may be made without your Consent, Authorization, or Opportunity to Object.

We may use or disclose protected health information in these following situations without your consent or authorization. These situations include:

Required by Law: We may use and disclose your protected health information if the use or disclosure is required by law. The use or disclosure will be made in compliance with the law.

Public Health: We may disclose your protected health information to public health authorities for purposes related to controlling disease, injury or disability. This includes:

  • Communicable Diseases: We may disclose your protected health information to a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading the disease or condition.
  • Health Oversight: We may disclose your protected health information for activities such as audits, investigations and inspections by government oversight agencies.
  • Abuse or Neglect: We may disclose your protected health information to report child abuse or neglect. In addition, we may disclose your protected health information if we believe that you have been a victim of abuse, neglect or domestic violence.

Food and Drug Administration: We may disclose your protected health information to report adverse events and product defects or problems; to enable product recalls; or to make repairs or replacements.

Legal Proceedings: We may disclose your protected health information in the course of any judicial or administrative proceeding.

Law Enforcement: We may also disclose protected health information to a law enforcement official for purposes such as legal proceedings; request for identification and location of a suspect, fugitive, material witness or missing person; pertaining to victims of a crime; and medical emergency that is likely that a crime has occurred.

Coroners and Funeral Directors: We may disclose protected health information to a coroner or medical examiner for identification purposes, determining cause of death or for the coroner or medical examiner to perform other duties. We may also disclose protected health information to a funeral director, in order to permit the funeral director to carry out their duties. We may disclose such information in reasonable anticipation of death.

Organ Donation: We may disclose protected health information to organizations involved in organ and tissue donation and transplant.

Research: We may disclose your protected health information to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and establish protocols to insure the privacy of your protected health information.

Criminal Activity: We may disclose protected health information, if we believe that the use of disclosure is necessary to prevent or lessen a serious and eminent threat to the health or safety of a person or the public.

Military Activity and National Security: We may use or disclose your protected health information to individuals who are armed forces personnel for activities deemed necessary by appropriate military command authorities, or for the purpose of a determination by the Department of Veterans Affairs of your eligibility for benefits. We may disclose your protected health information to authorized federal officials for conducting national security and intelligence activities, including for the provision of protective services to the President or others legally authorized.

Workers' Compensation: Your protected health information may be disclosed by us as authorized to comply with Workers¹ Compensation laws and other similar legally-established programs.

Correctional Facilities: We may use or disclose your protected health information if you are an inmate of a correctional facility and the Fire Division created or received your protected health information in the course of providing care to you.

5. Others Involved in your Health 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 protected health information that directly relates to that person¹s involvement in your health care. We may disclose protected health information to notify or assist in notifying a family member, personal representative or any other person that is responsible for your care, location, or death. Finally, we may disclose protected health information to an authorized public or private entity to assist in disaster relief efforts.

Emergencies. We may use or disclose your protected health information in an emergency situation.

Communication Barriers. We may use and disclose your protected health information if your physician or another physician in the practice attempts to obtain consent from you but is unable to do so due to communication barriers and the physician determines that you intend to consent to use or disclose under the circumstances.

6. Your Health Information Rights.

You have the Right to Inspect and Copy your Protected Health Information:This means you may inspect and obtain a copy of protected health information about you for as long as we maintain the protected health information.

Under federal law, there may be instances where you may not inspect or copy your protected health information. Depending on the circumstances, a decision to deny access may be reviewable. Please contact our privacy contact if you have any questions about access to your protected health information.

You have the Right to Request a Restriction of your Protected Health Information:This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or health care operations. You may also request that any part of your protected 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 request must state the specific restriction requested and to whom you want the restriction to apply.

The Fire Department is not required to agree to a restriction that you may request. If the Fire Department believes it is in your best interest to permit use and disclosure of your protected health information, your protected health information will not be restricted. If the Fire Department does agree to the requested restriction, we may not use or disclose your protected health information in violation of that restriction unless it is needed to provide emergency treatment. With this in mind please discuss any restriction you wish to request with the Fire Department.

You have the Right to Request to Receive Confidential Communications from us by Alternative means or at an Alternative Location:We will accommodate reasonable requests. Please make this request in writing to our privacy contact.

You may have the right to have the Fire Division amend your protected health information:This means you may request to have your protected health information changed for as long as we maintain this information. In certain cases, we may deny your request to have your protected health information changed. If we deny your request for a change, you have the right to disagree with us. Please contact our privacy contact if you have questions about making changes to your protected health information and how you can disagree with our decision.

You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information:This right applies to disclosures for purposes other than treatment, payment or healthcare operations as described in this Notice of Privacy Practices. It excludes disclosures we may have made to you, family members or friends involved in your care or for notification purposes. The right to receive this information is subject to certain exceptions, restrictions and limitations.

You have the right to obtain a paper copy of this notice from us:If you would like to have a more detailed explanation of these rights or if you would like to exercise one or more of these rights, contact our privacy contact.

7. 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 complaint with us by notifying our privacy contact of your complaint. We will not retaliate against you for filing a complaint.

You may contact our privacy contact, EMS Officer, Athena Robbins, at (937) 848-3272 for further information about the complaint process.

8. Change of Ownership

In the event that the Bellbrook Fire/EMS Department is merged with another organization, your protected health information/medical record will become the property of the new organization.

This notice was published and becomes effective on April 14, 2003.

For further information, please contact during business hours Monday- Friday, 8:00 AM to 3:00 PM:
BELLBROOK FIRE/EMS DEPARTMENT
ADMINISTRATION OFFICE
35 NORTH WEST STREET
BELLBROOK, OHIO 45305
(937) 848-3272