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.
If you have any questions about this notice, please
contact Monroe Ambulance’s Privacy Officer.
WHO MUST FOLLOW THIS NOTICE: This notice describes the privacy practices of Monroe Ambulance.
We are required by law to: Maintain the privacy of protected health
information; Give you this notice of our legal duties and privacy practices
regarding health information about you; and Follow the terms of our
notice that is currently in effect.
HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION:
The following categories describe ways that we may use and disclose
health information that identifies you (“Health Information”). Some
of the categories include examples, but every type of use or disclosure
of Health Information in a category is not listed. Except for the purposes
described below, we will use and disclose Health Information only with
your written permission. If you give us permission to use or disclose
Health Information for a purpose not discussed in this notice, you may
revoke that permission, in writing, at any time by Monroe Ambulance’s
For Treatment. We may use Health Information to treat
you or provide you with health care services. We may disclose Health
Information to doctors, nurses, technicians, or other personnel, including
people outside our facility who may be involved in your medical care.
For example, we may tell your primary physician about the care we provided
you or give Health Information to a specialist to provide you with additional
For Payment. We may use and disclose Health Information
so that we or others may bill or receive payment from you, an insurance
company or a third party for the treatment and services you received.
For example, we may give your health plan information about your treatment
so that they will pay for such treatment. We also may tell your health
plan about a treatment you are going to receive to obtain prior approval
or to determine whether your plan will cover the treatment.
For Health Care Operations. We may use and disclose
Health Information for health care operations purposes. These uses and
disclosures are necessary to make sure that all of our patients receive
quality care and for our operation and management purposes. For example,
we may use Health Information to review the treatment and services we
provide to ensure that the care you receive is of the highest quality.
Fundraising Activities. We may use Health Information
to contact you in an effort to raise money. We may disclose Health Information
to a related foundation or to our business associate so that they may
contact you to raise money for us.
Individuals Involved in Your Care or Payment for Your
Care. We may release Health Information to a person who is involved
in your medical care or helps pay for your care, such as a family member
or friend. We also may notify your family about your location or general
condition or disclose such information to an entity assisting in a disaster
Research. Under certain circumstances,
we may use and disclose Health Information for research purposes. For
example, a research project may involve comparing the health and recovery
of all patients who received one medication or treatment to those who
received another, for the same condition. Before we use or disclose
Health Information for research, though, the project will go through
a special approval process. This process evaluates a proposed research
project and its use of Health Information to balance the benefits of
research with the need for privacy of Health Information. Even without
special approval, we may permit researchers to look at records to help
them identify patients who may be included in their research project
or for other similar purposes, so long as they do not remove or take
a copy of any Health Information.
As Required by Law. We will disclose Health Information when required
to do so by international, federal, state or local law.
To Avert A Serious Threat to Health or Safety. We may
use or disclose Health Information when necessary to prevent or lessen
a serious threat to your health and safety or the health and safety
or the public or another person. Any disclosure, however, will be to
someone who may be able to help prevent the threat.
Business Associates. We may disclose Health Information
to our business associates that perform functions on our behalf or provide
us with services if the information is necessary for such functions
or services. For example, we may use another company to perform billing
services on our behalf. All of our business associates are obligated,
under contract with us, to protect the privacy of your information and
are not allowed to use or disclose any information other than as specified
in our contract.
Organ and Tissue Donation. If 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 or tissue donation and transplantation.
Military and Veterans. If you are a member of the armed
forces, we may release Health Information as required by military command
authorities. We also may release Health Information to the appropriate
foreign military authority if you are a member of a foreign military
Workers’ Compensation. We may release Health Information
for workers’ compensation or similar programs. These programs provide
benefits for work-related injuries or illness.
Public Health Risks. We may disclose Health Information
for public health activities. These activities generally include disclosures
to prevent or control disease, injury or disability; report births and
deaths; report child abuse or neglect; report reactions to medications
or problems with products; notify people of recalls of products they
may be using; track certain products and monitor their use and effectiveness;
notify a person who may have been exposed to a disease or may be at
risk for contracting or spreading a disease or condition; and conduct
medical surveillance of the hospital in certain limited circumstances
concerning workplace illness or injury. We also may release Health Information
to an appropriate government authority if we believe a patient has been
the victim of abuse, neglect or domestic violence; however, we will
only release this information if you agree or when we are required or
authorized by law.
Health Oversight Activities. We may disclose Health
Information to a health oversight agency for activities authorized by
law. These oversight activities include, for example, audits, investigations,
inspections and licensure. These activities are necessary for the government
to monitor the health care system, government programs, and compliance
with civil rights laws.
Lawsuits and Disputes. If you are involved in a lawsuit
or a dispute, we may disclose Health Information in response to a court
or administrative order. We also may disclose Health Information in
response to a subpoena, discovery request or other lawful process by
someone else involved in the dispute, but only if efforts have been
made to tell you about the request or to obtain an order protecting
the information requested.
Law Enforcement. We may release Health Information if
asked by a law enforcement official for the following reasons: (1) in
response to a court order, subpoena, warrant, summons or similar process;
(2) limited information to identify or locate a suspect, fugitive, material
witness, or missing person; (3) about the victim of a crime if, under
certain limited circumstances, we are unable to obtain the person’s
agreement; (4) about a death we believe may be the result of criminal
conduct; (5) about criminal conduct on our premises; and (6) in emergency
circumstances to report a crime, the location of a crime or victims,
or the identity, description, or location of the person who committed
Coroners, Medical Examiners and Funeral Directors. We
may release Health Information to a coroner or medical examiner. This
may be necessary, for example, to identify a deceased person or determine
the cause of death. We also may release Health Information to funeral
directors as necessary for their duties.
National Security and Intelligence Activities. We may
release Health Information to authorized federal officials for intelligence,
counter-intelligence, and other national security activities authorized
Protective Services for the President and Others. We
may disclose Health Information to authorized federal officials so they
may provide protection to the President, other authorized persons or
foreign heads of state or conduct special investigations.
Inmates or Individuals in Custody. If you are an inmate
of a correctional institution or under the custody of a law enforcement
official, we may release Health Information to the appropriate correctional
institution or law enforcement official. This release would be made
only if necessary (1) for the institution to provide you with health
care; (2) to protect your health and safety or the health and safety
of others; or (3) for the safety and security of the correctional institution.
You have the following rights regarding Health Information we maintain
Right to Inspect and Copy. You have the right to inspect
and copy Health Information that may be used to make decisions about
your care of payment for your care. To inspect and copy this Health
Information, you must make your request, in writing, to Monroe Ambulance’s
Right to Amend. If you feel that Health Information
we have is incorrect or incomplete, you may ask us to amend the information.
You have the right to request an amendment for as long as the information
is kept by or for us. To request an amendment, you must make your request,
in writing, to Monroe Ambulance’s Privacy Officer.
Right to an Accounting of Disclosures. You have the
right to request an accounting of certain disclosures of Health Information
we made. To request an accounting of disclosures, you must make your
request, in writing, to Monroe Ambulance’s Privacy Officer.
Right to Request Restrictions. You have the right to
request a restriction or limitation on the Health Information we use
or disclose for treatment, payment, or health care operations. In addition,
you have the right to request a limit on the Health Information we disclose
about you to someone who is involved in your care or the payment of
your care, like a family member or friend. For example, you could ask
that we not share information about your surgery with your spouse. To
request a restriction, you must make your request, in writing, to Monroe
Ambulance’s Privacy Officer. We are not required to agree with your
request. If we agree, we will comply with your request unless we need
to use the information in certain emergency treatment situations.
Right to a Paper Copy of This Notice. You have the right
to a paper copy of this notice. You may ask us to give you a copy of
this notice at any time. Even if you have agreed to receive this notice
electronically, you are still entitled to a paper copy of this notice.
To obtain a paper copy of this notice, write to:
Monroe Ambulance Privacy Officer
1669 Lyell Avenue
Rochester, New York 14606
CHANGES TO THIS NOTICE:
We reserve the right to change this notice. We reserve the right to
make the revised or changed notice effective for Health Information
we already have as well as any information we receive in the future.
We will post a copy of the current notice at the hospital. The notice
will contain the effective date on the first page, in the top right-hand
If you believe your privacy rights have been violated, you may file
a complaint with us or the Secretary of the Department of Health and
Human Services. To file a complaint with us, contact Monroe Ambulance’s
Privacy Officer. All complaints must be made in writing. You will not
be penalized for filing a complaint.