MODEL NOTICE OF PRIVACY PRACTICES

OF Premier Medical Transport

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 information is personal, and we are committed to protecting it.  Your health information is also very important to our ability to provide you with quality care, and to comply with certain laws.  This Notice applies to all records about your care that our personnel create.  (Your physician may have different policies and a different notice regarding your health information that is created in the physician’s office.)  In addition, the hospital at which you receive care may also have different policies and a different Notice regarding your health information.

We Are Legally Required to Safeguard Your Protected Health Information.

We are required by law to:

maintain the privacy of your health information, also known as “protected health information” or “PHI”,

provide you with this Notice, and

comply with this Notice.

Future Changes to Our Practices and This Notice.

We reserve the right to change our privacy practices and to make any such change applicable to the PHI we are obtained about you before the change, as well as to Information we receive in the future.  If a change in our practices is material, we will revise this Notice to reflect the change.  You may obtain a copy of any revised Notice by contacting the billing department at (714) 353-9556.  We will also make any revised Notice available in our main office 4050 N. Palm Street, Suite 501, Fullerton, Ca. 92835.

How We May Use and Disclose Your Protected Health Information.

The law requires us to obtain your prior authorization for some uses and disclosures.  In other circumstances, the law allows us to use or disclose PHI without your authorization.  This Section III gives examples of each of these circumstances.

Uses and Disclosures that do not Require Your Authorization.  We may use or disclose your PHI to provide treatment to you or in order for others to provide treatment to you.  For example, we may disclose your PHI to your physicians, nurses, and other health care personnel who are involved in yr care.

We may also use or disclose your PHI to your insurance carrier in order to get paid for treatment provided to you.  For example, we may use your PHI to create the bills that we submit to the insurance company, or we may disclose certain portions of your PHI to our business associates who perform billing and claims processing or other services for us.  We may also disclose your PHI to another health care provider or insurance company for their payment-related activities, such as to get paid for treatment provided to you or to process claims under your health insurance plans.

We may also use or disclose your PHI for our operations related to health care.  For example, we may use your PHI to evaluate the quality of care you received from us, or to evaluate the performance of those involved with your care.  We may also provide your PHI to our attorneys, accountants and other consultants to make sure we are complying with the laws that affect us.  We may also provide your contact information (such as name, address and phone number) and the dates you received services from us, or to a foundation that helps us with our fundraising efforts.  In addition, we may also disclose your PHI to another health care provider, health insurance plan or health care clearinghouse for purposes of their operations related to health care.  However, we will only do so if they have or have had a relationship with you and if the PHI they request pertains to that relationship.  In addition, we will disclose your PHI to these third parties for limited purposes only, such as for them to conduct quality improvement activities, or to review the performance of a health care provider, or for training purposes.

There are stricter requirements for use and disclosure for some types of PHI, for example, rug and alcohol abuse patient information and HIV tests.  However, there are still limited circumstances in which these types of information may be used or disclosed without your authorization.

Uses and Disclosures That Require Us to Give You the Opportunity to Object.  If you do not object, we may provide relevant portions of your PHI to a family member, friend, or other person you indicate is involved in your health care or in helping you get insurance coverage or otherwise provide for payment for your health care.  We may use or disclose you PHI to notify your family of personal representative of your location or condition.  In an emergency or when you are not capable of agreeing or objecting to these disclosures, we will disclose PHI as we determine is in your best interest, but will give you the opportunity to object to future disclosures to your family and friends if possible.  Unless you object, we may also disclose your PHI to persons performing disaster relief activities.

Certain Uses and Disclosures Do Not Require Your Authorization.  The law allows us to disclose PHI without your authorization in 

When Required by Law.  We disclose PHI when we are required to do so by federal, state, or local law.

For Public Health Activities.  For example, we disclose PHI when we report adverse reactions to a drug or medical device, or to notify a person who may have been exposed to a disease in compliance with applicable law. We may also report PHI the local emergency medical services agency in connection with its oversight role over ambulance services.  We may also use and disclose your PHI as necessary to comply with federal and state laws that govern workplace safety.

For Reports About Victims of Abuse, Neglect or Domestic Violence.  We will disclose your PHI in these reports only if we are required or authorized by law to do so, or if you otherwise agree.

To Health Oversight Agencies.  We will provide PHI as requested to government agencies who have authority to audit or investigate our operations.

For Lawsuits and Disputes.  If you are involved in a lawsuit or dispute, we may disclose your PHI in response to a court order or administrative order.  We may also disclose your PHI in response to a subpoena or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request (which may include written notice to you) or to obtain a court order that will protect the PHI requested.

To Law Enforcement.  We may release PHI as permitted by law if asked to do so by a law enforcement official.  In the following circumstances: (a) In response to a court order issued by a court in the county where the records are located, grand-jury subpoena, court-ordered warrant, administrative request or similar process; (b) to identify or locate a suspect, fugitive, material witness or missing person; (c) about the victim of a crime if, under certain limited circumstances, we are unable to obtain the person’s agreement; (d) about a death we believe may be due to criminal conduct; (e) about criminal conduct at our facility; and (f) in emergency circumstances, to report a crime, its location or victims, or the identity, description or location of the person who committed the crime.

To Coroners, Medical Examiners and Funeral Directors.  We may disclose PHI to facilitate the duties of these individuals.

To Organ Procurement Organizations.  We may disclose PHI to facilitate organ donation and transplantation.

To Avert a Serious Treat to Health or Safety.  We may disclose your PHI to someone who can help prevent a serious threat to your health and safety or the health and safety of another person or the public.

For Specialized Government Functions.  For example, we may disclose your PHI to authorized federal officials for intelligence and national security activities that are authorized by law, or so that they may provide protective services to the President or foreign heads of state or conduct special investigations authorized by law.

To Workers’ Compensation or Similar Programs.  We may provide your PHI to these programs in order for you to obtain benefits for work-related injuries or illness.

If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release your PHI to the correctional institution or law enforcement official as necessary for the institution to provide you with health care, to protect your health or safety or that of others or for the safety

and security and security of the correctional institution.

Other Uses and Disclosures of Your Protected Health Information.

Other uses and disclosures of your PHI that are not covered by this Notice or the laws that apply to us will be made only with your written authorization.  If you give us written authorization for a use or disclosure of your PHI, you may revoke that authorization, in writing, at any time.  If you revoke your authorization we will no longer use or disclose your PHI for the purposes specified in the written authorization, except that we are unable to take back any disclosure we have already made with your permission.  In addition, we can use or disclose your PHI after you have revoked your authorization for actions we have already taken in reliance on your authorization.  We are also required to retain certain records of the uses and disclosures made when authorization was in effect.