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 CAREFULLY

As an essential part of our commitment to you, Pittsfield Ambulance 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 healthcare information and to provide you with the attached Notice of Privacy Practices.  The Notice outlines our legal duties and privacy practices to respect your PHI. It not only describes our privacy practices and your legal rights, but lets you know, among other things, how Pittsfield Ambulance is permitted to use and disclose PHI about you, how you can access and copy that information, and how you may request restrictions on our use and disclosure of your PHI.   Pittsfield Ambulance 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 healthcare information about our
patients with care under strict policies of confidentiality that all of our staff is committed to following.

Please read the attached detailed notice. If you have any questions about it please contact our Privacy Officer at (603) 435-6807

Notice of Privacy Practices

This Notice describes how Medical information about you may  be used and disclosed and how you can get access to this information.

Purpose of this Notice: Pittsfield Ambulance is required by law to maintain the privacy of certain confidential healthcare 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 Pittsfield Ambulance is permitted to use and disclose PHI about you.

Pittsfield Ambulance 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. Use and Disclosures of PHI: Pittsfield Ambulance may use PHI for the purposes of treatment, payment, and healthcare 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 healthcare 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 (either directly or through a third party billing company), management of billed claims for services rendered, medical necessity determinations and reviews, utilization review, and collection of outstanding accounts.

For Healthcare 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.

Use and Disclosure of PHI Without Your Authorization: Pittsfield Ambulance is permitted to use PHI without your written authorization, or opportunity to object in certain situations, including:
•   For Pittsfield Ambulance’s use in treating you or in obtaining payment for services provided to you or in other healthcare operations;
•   For the treatment activities of another healthcare provider;
•   To another healthcare 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 healthcare provider (such as the hospital to which you are transported) for the healthcare 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 healthcare fraud and abuse detection or for activities related to compliance with the law;
•   To a family member, or other relative, or close personal friend or other individual involved in your care if we obtain your verbal agreement to do so or it we give you an opportunity to object to such a disclosure and you to 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 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 healthcare 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 serious threat to the health and safety of a person or the public at large;
•   For workers’ compensation purposes, and incompliance 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 office 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 healthcare operations, or when we share your health information with our business associates like our billing company or a medical facility from which we have transported. 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 healthcare operations, or to restrict the information that is provided to family, friends and other individuals involved in your healthcare. But if you request a restriction and the information you use to restrict is needed to provide you with emergency treatment, then we may use the PHI or disclose the PHI to a healthcare provider to provide you with emergency treatment. Pittsfield Ambulance is not required to agree to any restrictions you request, but any restrictions agreed to by Pittsfield Ambulance are binding on Pittsfield Ambulance.

Revision to the Notice: Pittsfield Ambulance 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. 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 in this Notice, please contact:

Pittsfield Ambulance Service
Privacy Officer
33 Catamount Road
Pittsfield, NH 03263
(603) 435-6807

Acknowledgement of Receipt of Notice of Privacy Practices

I hereby acknowledge that I have been provided with a copy of Pittsfield Ambulance’s Notice of Privacy Practices on this date.


Date: 
Signature: 
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Street Address:
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