NORTH PRAIRIE FIRE DEPARTMENT NOTICE OF PRIVACY PRACTICES     3-24-2004

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 Care Information-Protecting Your Privacy: It is your right as a patient to be informed of the privacy practices of your health care provider, as well as to be informed of your privacy rights with respect to your personal health information (may be referred to as PHI). This Notice of Privacy Practices is intended to provide you with this information.

 

The North Prairie Fire Department's Responsibilities: It is your right as a patient to be informed of the North Prairie Fire Department's (here after referred to as NPFD) legal duties with respect to protection of the privacy of your personal health information.

 

The NPFD is required to:                                                                                                                                  

$   Maintain the privacy of your health information;

$   Provide you with a notice of the legal duties and privacy practices regarding protected health information collected and maintained about you

$   Abide by the terms of this notice.

The NPFD reserves the right to change the terms of the notice of privacy practices and make the new notice provisions effective for all protected health information that it maintains. The NPFD also reserves the right to change the terms of its notice with respect to any applicable and more limited uses and disclosures.

The NPFD will promptly revise and distribute its notice whenever NPFD makes a substantial change to any of its privacy practices.

The NPFD will not use or disclose your health information without your authorization, except as described in this notice.

 

 YOUR HEALTH INFORMATION RIGHTS:

You have the right to:

$   Request a restriction on certain uses and disclosures of your health information: You have the right to request restrictions on certain uses and disclosures of PHI, even if the restriction affects your treatment, or NPFD's payment or health care operation activities. However, NPFD is not required to agree to your requested restriction. For example, if you are a member of the department and you receive health care services from the department, you  may request that your health care record not be maintained in the general record filing area.

$  Receive Confidential Communications: You have the right to request that the NPFD communicate your health information to you by alternative means or at alternative locations. The NPFD shall accommodate reasonable requests. For example, you may request to be contacted at a phone number that is different from the phone number listed in your health care record.

$  Inspect and obtain a copy of your health record: You have the right to inspect and obtain a copy of your health care record. This request for access to your health care record must be submitted in writing to the Privacy Officer listed on the back of this notice. This right may not apply to certain types of psychotherapy notes and the NPFD may charge you a reasonable fee for a copy of your health care record.

$  Amend your health record: You have the right to request an amendment to your health care record if you believe your health information is incorrect or incomplete. You may be asked to make this request in writing and state the reason why your health record should be changed. If the NPFD did not create the health information you believe is incorrect or if the NPFD disagrees with you, the NPFD may deny your request. For example, if you believe that information in your medical history is incorrect, such as your birth date, you may request that this information be amended.

$  Obtain an accounting of disclosures of your health information: You have the right to an accounting of disclosures of your health information that the NPFD has made in compliance with state and federal law. The accounting will describe the dates of each disclosure, a brief description of information disclosed and the reason for disclosure. You will receive one accounting per year at no charge and the NPFD may charge you a reasonable fee for each subsequent request.

$  Obtain a paper copy of this notice upon request: You have the right to obtain a paper copy of this notice upon request.

 

Uses and disclosures for Treatment, Payment and Health Care Operations: The NPFD is permitted by the federal privacy rule to use or disclose your protected health information for treatment, payment or health care operations.

 

The NPFD may use or disclose your health information for treatment: The NPFD may use or disclose your PHI in the provision, coordination or management of your health care.

 

The NPFD may use or disclose your health information for payment: The NPFD may use or disclose your PHI to obtain reimbursement for the provision of health care services. The bill may include information that identifies you, your diagnosis and your treatment.

 

The NPFD may use or disclose your health information for routine health care operations: The NPFD may use or disclose your PHI for evaluation of patient care services, evaluating the performance of health care providers, or activities relating to compliance with the law, and business planning and development.

Example: The North Prairie Fire Department may review your health record to determine the efficiency of the services provided to you.

 

Uses or Disclosures of Your Protected Health Information Permitted Without Your Authorization: Without your written authorization, the NPFD may use or disclose your health information for the following purposes:

 

As required by law: The NPFD may use or disclose protected health information to the extent that the use or disclosure is required by law and the use or disclosure complies with and is limited to the relevant requirements of the law. Uses or disclosures required by federal privacy rule and limited by the more protective requirements of state law include the following:

$   Disclosures about victims of elder or child abuse;

$   Disclosures for judicial and administrative proceedings; or

$   Disclosures for law enforcement purposes.

 

Public health: As required by law, the NPFD may disclose your protected health information (PHI) to the State of Wisconsin for the purpose of statutory reporting.

The NPFD may disclose your PHI excluding mental health, alcohol or drug abuse or developmental disability or HIV test result to a state or federal public health agency for the purpose of preventing or controlling disease, injury or disability.

The NPFD may disclose your PHI excluding your HIV test result without your authorization to a county agency investigating child abuse.

The NPFD may disclose your PHI excluding mental health, alcohol or drug abuse or developmental disability or HIV test result without your authorization to the Food and Drug Administration (FDA).

The NPFD may disclose your HIV test result without your authorization to a person that may have sustained a contact that carries a potential for transmission of HIV.

The NPFD  may disclose your PHI reasonably related to a work related illness or injury if an application for workers' compensation has been filed.

 

Victims of abuse, neglect or domestic violence: The NPFD may disclose health information except for an HIV test result if  the NPFD believes that individual is a victim of child or elder abuse.

 

Health oversight activities: The NPFD will not disclose HIV test results to health care oversight agencies without an authorization. The NPFD may disclose your mental health, alcohol or drug abuse or developmental disability related health information to the Department of Health and Family Services, to the county for coordination of human services and to a representative of the board on aging and long-term care. The remainder of your PHI may be disclosed without your authorization to a state or federal agency.

 

Judicial and Administrative Proceedings: The NPFD may disclose your PHI in response to a court order. The NPFD may disclose your PHI in response to a subpoena if the NPFD is a party to a court action, the NPFD has received your authorization to disclose, and has not complied within two business days or the NPFD failed to respond to a request for worker's compensation records. The NPFD may disclose your PHI excluding mental health, alcohol or drug abuse or developmental disability or HIV test result in response to a subpoena from a state or federal agency.

 

Law Enforcement: The NPFD may disclose your PHI except for HIV test results to county law enforcement officials for the reporting and investigation of elder and/or child abuse. The NPFD may disclose your Pill except for mental health, alcohol or drug abuse or developmental disability or HIV test results to state and federal law enforcement officials. The NPFD may disclose mental health, alcohol or drug abuse, or developmental disability PHI for limited law enforcement purposes as required by law. The NPFD may disclose your PHI to a law enforcement official in response to a court order.

 

For activities related to death: Coroner or Medical Examiner: The NPFD may use or disclose your PHI that is not an HIV test result or related to mental health, alcohol or drug abuse, and developmental disabilities to a coroner or medical examiner.

 

To avoid a serious threat to health or safety: The NPFD may disclose your PHI under limited circumstances to law enforcement officials to avert a serious threat to health or safety.

 

Disclosures for specialized government functions: The NPFD may disclose PHI excluding mental health, alcohol or drug abuse, or developmental disability or HIV test result for national security, for protection of the President, and for medical suitability determination of Armed Forces personnel to a state or federal agency.

 

Workers compensation: the NPFD may disclose PHI reasonably related to a workers' compensation injury

The NPFD has attempted to explain with this notice the circumstances where state law may be  more protective than the federal privacy rule and provides greater privacy protection.

Except for the situations listed above and treatment, payment or health care operations purposes, the use or disclosure of your health information requires NPFD to obtain your written authorization. You  may  withdraw your authorization in writing at any time by submitting your written withdrawal to the NPFD Privacy Officer(s) listed below.

 

Patient complaint Process : If you believe your privacy rights have been violated, you may file a complaint with the NPFD or with the Secretary of the Department of Health and Human Services., There will be no retaliation against you for filing a complaint.

To file a complaint with the NPFD please contact the NPFD Privacy Officer who will provide you with the necessary assistance.

 

Questions or Concerns: If you have any questions or concerns regarding your privacy rights or the information in this notice, please contact the NPFD Privacy Officer at:

 

North Prairie Fire Department

P.O. Box 296

North Prairie, Wisconsin 53153

Phone:  (262) 392-2700

Fax:      (262) 392-2121

E-Mail: ems@northprairiefd.com

Effective Date: This Notice of Privacy Practice is effective as of  October 1, 2003.