of Privacy Practices
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
Fire Department 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. Pittsboro Fire Department is also required to abide by the
terms of the version of this Notice currently in effect.
Use and disclosure of PHI: Pittsboro Fire Department may use PHI for the purposes of
treatment, payment, and health care operations, in most cases
without your written permission. Examples of our use of your PHI:
Treatment: This includes such things as obtaining verbal and written
information about your medical condition and treatment from you
as well from others, such as doctors and nurses who give orders
to allow us to provide treatment to you. We may file your PHI to other health care providers
involved in your treatment, and may transfer your PHI to other
health care providers involved in your treatment, and may
transfer you PHI via radio or telephone to the hospital or
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 bills to insurance companies, making
medical necessity determination and collecting outstanding
Health care operations: This includes quality assurance activities, licensing,
and training programs to ensure that our personnel meet out
standards of care and follow established policies and procedures
as well as certain other management functions.
and Disclosure of PHI Without Your Authorization. Pittsboro Fire Department is permitted to use PHI without
your written authorization, or opportunity to object, in certain
situations, and unless prohibited by more stringent state law,
the treatment, payment or health care operations activities of
another health care provider who treats you.
health care and legal compliance activities.
a family member, other relatives, 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
a public health authority in certain situations as required by
law (such as to report abuse, neglect or domestic violence)
health oversight activities including audits or government
investigations, inspections, disciplinary proceedings, and
other administrative or judicial actions undertaken by the
government (or their contractors) by law to oversee the health
judicial and administrative proceedings as required by a court
or administrative order, or in some cases in response to a
subpoena or other legal process.
law enforcement activities in limited, such as when responding
to a warrant.
military, national defense and security and other special
avert a serious threat to the health and safety of a person or
the public at large.
workers’ compensation purposes, and in compliance with
workers’ compensation laws.
coroners, medical examiners, and funeral directors for
identifying a deceased person, determining cause of death, or
carrying on their duties as authorized by law.
you are an organ donor, we may release health information to
organizations that handle organ procurement or organ, eye or
tissue transplantation or to an organ donation bank, as
necessary to facilitate organ donation and transplantation.
research projects, but this will be subject to strict
oversight and approvals
may also use or disclose health information about you in a way
that does not personally identify you or reveal who you are.
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 that authorization.
Rights: As a patient,
you have a number of rights with respect to your PHI, including:
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 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 our privacy officer.
right to amend your PHI: Your 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
right to request to restrict the uses and disclosure of your PHI. You have the right to request that we restrict how we use
and disclose your medical information that we have about you. Pittsboro Fire Department is not required to agree to any
restrictions you request, but any restrictions agreed to by
Pittsboro Fire Department in writing are binding on Pittsboro
right to request a Paper Copy Notice: You
have the right to request any additional copies of this form as
needed. This is
supplied to you at any time at
www.pittsborofire.org. You also have the option to come to the Pittsboro Fire
Department administration office and request a copy during
normal business hours.
to the Notice: Pittsboro Fire Department reserves the right to change 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
to our web site, if we maintain one at that time. You can get a copy of the latest version by contacting our
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 if 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 inquiries to our privacy officer.
Officer Contact Information:
Dan Huff, EMS Coordinator
Pittsboro Fire Department
400 East Main
Pittsboro, IN. 46167
of Notice: March 30,