CITY OF MISHAWAKA / EMS
THIS NOTICE DISCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY
BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW IT CAREFULLY.
City of Mishawaka/EMS is required by law to maintain the privacy
of certain confidential health care information, known as Protected
Health Information of PHI, and to provide you with a notice of our
legal duties and privacy practices with respect to you PHI. City
Of Mishawaka/EMS is also required to abide by the terms of the version
of this Notice currently in effect.
Uses and Disclosures of PHI: City Of Mishawaka/ EMS may
use PHI for the purposes of treatment, payment, and health care
operations, in most cases without written permission. Examples of
our use of your PHI:
For treatment. This includes such things as obtaining verbal
and written information about your medical condition and treatment
from you as well as from others, such as doctors and nurses who
give orders to allow us to provide treatment to you. We may give
your PHI to other health care providers involved in your treatment,
and may transfer your PHI via radio or television to the hospital
or dispatch center.
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 submitting medical bills to insurance companies,
making medical necessity determinations and collecting outstanding
accounts.
Reminders for Scheduled Transports and Information on Other
Services. We may also contact you to provide you with a reminder
of any scheduled appointments for non-emergency ambulance and medical
transportation, or to provide information about other services we
provide.
Use and Disclosure of PHI Without Your Authorization. City
Of Mishawaka/EMS is permitted to use PHI without your written authorization,
or opportunity to object, in certain situations, and unless prohibit
by a more stringent state law, including:
- For the treatment, payment or health care operations activities
of another health care provided who treats you.
- For health care and legal compliance activities.
- To a family member, other relative, or close personal friend
or other individual involved in your care if we obtain your verbal
agreement to do so or if we give you an opportunity to object
to such a disclosure and you do not raise an objection, and in
certain other circumstances where we are unable to obtain your
agreement and believe the disclosure is in your best interest;
- To a public health authority in certain situations as required
by law (such as to report abuse, neglect or domestic violence;)
- For health oversight activities including audits or government
investigations, inspections, disciplinary proceedings, and other
administrative or judicial actions undertaken by the government
(or their contractor) by law to oversee the health care system;
- For judicial and administrative proceedings as required ob 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;
- 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 purposes, 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 health information
to organizations that handle organ procurement of 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;
- We may also 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. 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 the authorization.
Patient Rights: As a patient, you have a number of rights
with respect to your PHI, including:
The right to access, copy or inspect your PHI. This means
you may 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 of we deny you access
and let you know your appeal rights. You may also have the right
to receive confidential communications of your PHI. If you wish
to inspect and copy your medical information, you should contact
our privacy officer.
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 our privacy officer.
The right to request an accounting. You may request an accounting
from us of certain disclosures of your medical information that
we have made in the 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 health
care operations, or when we share your health information with our
business associates, like our billing company or a medical facility
from/to which we have transported you. 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, contact our privacy officer.
The right to request that we restrict the uses and disclosures
of you PHI. You have the right to request that we restrict how
we use and disclose your medical information that we have about
you. City Of Mishawaka/EMS is not required to agree to any restrictions
you request, but any restrictions agreed to by City Of Mishawaka/EMS
in writing are binding on City Of Mishawaka/EMS
Internet, Electronic Mail, and the Right to obtain Copy of
Paper Notice on Request. If we maintain a web site, we will
prominently post a copy of this Notice on our web site. If you allow
us we will forward you this Notice by electronic mail instead of
on paper and you may always request a paper copy of the Notice.
Revisions to the Notice: City Of Mishawaka/EMS reserves
the right to chance 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 and posted to our
web site, if we maintain one. You can get a copy of the latest version
of this Notice by contacting our privacy officer.
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 of 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 inquires
to our privacy officer.
Privacy Officer Contact Information:
Privacy Officer
City Of Mishawaka
600 E. Third Street
Mishawaka, In. 46545
Telephone: 574-258-1622
Fax: 574-258-1724
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