Burton Volunteer Fire Department, Inc

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. PLEASE REVIEW IT CAREFULLY.

Burton Volunteer Fire Department, Inc. 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. Burton Volunteer Fire Department, Inc., is also required to abide by the terms of the version of this notice currently in effect.

Uses and Disclosures of Medical Information: Burton Volunteer Fire Department, Inc., may use or disclose your PHI in order to provide you with treatment, collect payment for services, and to conduct other health care operations, in most cases, without your authorization. Examples of our uses of your confidential medical information are as follows:

For Treatment. This includes, but is not limited to, obtaining verbal or written information about your medical condition and treatment from you as well as others, such as doctors or nurses who give orders to allow us to provide treatment to you. We may disclose your PHI to other health care providers involved in your treatment, and may transfer your PHI via radio or telephone to the hospital or dispatch center.

For Payment. Burton Volunteer Fire Department, Inc., may use or disclose your medical information so that the treatment you received can be billed to, and payment can be collected from, you, an insurance company, or third party payer.

For Health Care Operations. Burton Volunteer Fire Department, Inc., may use or disclose your medical information to comply with accreditation and other standards and to make sure that all patients receive quality care.

Use and Disclosure of Medical Information Without your Authorization. Burton Volunteer Fire Department, Inc., is permitted to use your PHI without your written authorization, or opportunity to object, in certain situations, and unless prohibited by a more stringent Ohio law, including, but not limited to:

For the treatment, payment or health care provider who treats you;

For health care and legal compliance activities;

To a family member, personal representative, power of attorney or friend who is involved in your medical care or who helps pay for your care. In addition, we may disclose your medical information to an entity assisting in disaster relief efforts so that your family can be notified about you condition, status and location.

To public health authority in certain situations as required by law, such as:

1. To prevent or control disease, injury or disability;

2. Report abuse, neglect or domestic violence.

· Health oversight activities, which include audits, government investigations, inspections and licensure or disciplinary action. These activities are necessary for the government to monitor the health care system, government programs and compliance with civil rights laws.

· For judicial and administrative proceeding 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 responding to a warrant.

· To provide information about a victim of a crime;

· About criminal conduct that occurred on our premises;

· 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 purpose, 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 medical information to organizations that handle organ procurement and/or organ, eye or tissue transplantation or to an organ donation bank, as necessary to facilitate organ donation and transportation;

· We may also use or disclose medical 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 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 your medical information, including:

Right to Inspect and Copy. You have the right to inspect and have a copy made of medical information that we maintain. We will provide you with access to your medical information requested within 30 days of you written request. We may also charge a fee for you to copy any medical information that you have a right to access. You do not have the right to obtain information if its disclosure would have an adverse effect on you or if the information is compiled by us in reasonable anticipation of, or for use in, a civil, criminal, or administrative action or proceeding. In limited circumstances, we may deny you access to your medical information, and you may appeal certain types of denials. We will provide a written response if we deny you access and let you know your appeal rights. You also have the right to receive confidential communications of your PHI. If you wish to inspect and copy your medical information, you should contact the Fire Chief.

The Right to Amend Your PHI. If you feel that you’re medical information that we maintain is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as we maintain the information. We will amend your information within 60 days of your request and will notify you when we have amended your medical information. We are permitted by law to deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that was not created by us, is not part of the medical information maintained by us, is not part of the information which you would be permitted to inspect and copy; or is accurate and complete. If you wish to request that we amend the medical information that we maintain, you should contact the Fire Chief.

Right to an Accounting of Certain Disclosures. You have the right to request an accounting of certain disclosures, which we made of your medical information within the last six years prior to your request. This right applies to disclosures for purpose other than treatment, payment, or health care operations, or when shared with business associates, like our billing company or a medical facility to which we have transported you. It excludes disclosure we may have made to you, with your authorization, to family members or friends involved in your care, or for notification purposes. If you wish to request an accounting, submit your request in writing to the Fire Chief. Your request must state a time period which may not be longer than six years and may not include dates before April 14, 2003

Right to Request Restrictions. You have the right to request restriction or limitation on the medical information we use or disclose about you for treatment, payment, or health care operations. You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend. Burton Fire Department, Inc., is not required to agree to your request. If we do agree, we will comply with your request unless information is needed to provide you with emergency treatment. To request restrictions, you must make your request in writing to the Fire Chief.

Right to Request Change in Communications. You have the right to request that we communicate with you about your medical information in a certain way or at a certain location. For example, by electronic mail or postal service.

Right to a Paper Copy of this Notice. You have the right to receive a paper copy of this notice. You may ask us to give you a copy of this notice at any time. To obtain a paper copy of this notice, please contact the Fire Chief.

CHANGES TO THIS NOTICE

Burton Volunteer Fire Department, Inc., reserves the right to change this Notice. Burton Volunteer Fire Department, Inc., reserves the right to make the revised or changed Notice effective for all medical information which we already have about you as well as any information we have received or created in the future. The Notice will prominently display its effective date. We will post a copy of its current Notice at our Fire Station and at www.burtonfire.com.

COMPLAINTS

If you believe your privacy rights have been violated, you may file a complaint with us or with the Secretary of the Department of Health and Human Services. To file a complaint with us, contact the Fire Chief. All complaints must be submitted in writing.

You will not be penalized by The Burton Volunteer Fire Department, Inc., on the grounds that a complaint was filed.

Contact Information:

Burton Volunteer Fire Department, Inc.

13828 Spring Street

PO Box 243

Burton, Ohio 44024

Phone (440) 834-4416

Fax (440) 834-0490

URL: www.burtonfire.com

Effective Date of the Notice: April 14, 2003