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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, 235 Old Jesup Rd, Brunswick, GA, 31520, #1-912-264-1420 or 1-912-267-5717.

 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. 

* 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, 235 Old Jesup Rd., Brunswick, GA 31520, #1-912-264-1420 or 1-912-267-5717. 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.