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HIPAA Privacy
Policy Notice:
This notice describes our
privacy policy, your rights, and how your health information may be used
and disclosed to others. Please review it carefully. Your health and
your privacy are our concerns.
Our company wishes to inform
you of your rights regarding your private health care information. You
have the right to review our privacy policy prior to signing the
acknowledgment form. By signing this notice you acknowledge that you
have had the opportunity to review our privacy policy. If you want a
copy of this policy or in the event that our policy changes you want a
revised copy please contact us at Glynn Co. Fire-EMS, 121 Public
Safety Boulevard, Brunswick, GA, 31525, #1-912-554-7779 or 1-912-269-3700.
You also have the right to
request that we restrict the method in which we use or disclose your
health information for purposes of treatment, payment or health care
operations. We have the right to refuse to comply with your request.
By signing this form, you
expressly acknowledge our use and disclosure of your health information
for purposes of your treatment, payment, or other health care
operations. This notice will not expire and will apply to services
provided to you from this day forward.
We will keep and record
information about your medical condition. We may use this information or
disclose this information to others as follows:
We may use or disclose your
health information in order to treat you. For example, we may
advise the health care provider which we are transporting you to of your
medical condition, including your vital signs and medications we have
administered to you. We may also disclose your condition to family or
care-givers who are involved in your medical care.
We may use or disclose your
health information in order to receive payment for the services we
provide to you. For example, we may disclose your condition in order for
your insurance company to understand why you received treatment so that
they will pay your claim. We may also disclose your information to our
billing department/billing company/attorney in order to seek payment for
the services we provide to you.
We may use or disclose your
health information for our operations. For example, we may review your
information in order to evaluate your treatment and our services in
order to insure that our care for you now and in the future is the best
that it can be. We may use your health information to contact you in the
future. We may also disclose your information as required by law.
YOUR RIGHTS
REGARDING YOUR MEDICAL INFORMATION:
* Right to Inspect and
Copy your Information: You may review and copy your medical records
and information. You should make such a request to us at Glynn Co.
Fire-EMS, 121 Public Safety Boulevard, Brunswick, GA 31525, #1-912-554-7779 or
1-912-269-3700. We have the right to charge a reasonable fee for all
copying and mailing expenses.
* Right to Amend: You
may ask that we amend your health information if you believe that your
information is incomplete or incorrect. A request for an amendment
should be made in writing and should be sent to us at the above address.
Your request must be accompanied by a statement from you regarding why
you feel the amendment is proper. We may deny your request if it is not
written or if you fail to state a reason for the proposed amendment. We
may also deny your request if you ask us to amend information that is
not part of the information we keep, was not created by us (unless the
entity responsible is no longer available), is not part of the
information available for you to inspect and copy, or is accurate and
complete.
* Right to Know about
Disclosures: You have the right to request an accounting of who we
have disclosed your health information to. The request should be made in
writing and sent to us at the above address. You must state a time
period for your request (for a particular date of service), which can
not be longer than 6 years. Your first request every 12 months is free.
After that we may charge you for additional requests made within 12
months of your last request. Please contact us for the exact cost.
* Right to Request
Restrictions: You may request a restriction or limitation on how and
what health information we disclose regarding you for treatment, payment
of health operations or to your family or care-givers. We do not have to
agree to your request. Requests for restrictions must be made in writing
and sent to us at the above address. Your request must include a
statement of what information you want to limit, whether you want to
limit its use, disclosure, or both, and to whom you want the limits to
apply.
* Right to Confidential
Communications: You may request that we communicate with you about
medical matters in a certain format or at a specific location. You must
request such a confidential communication or specific type or place of
communication in writing submitted to us at the above address. No reason
for this request is necessary and we will honor all reasonable requests.
* Right to Receive a Copy
of this Notice: You may request and receive a written copy of this
Notice (or our current notice) and copy of our "Privacy Policy Notice"
at any time by contacting us at the above address. |
