Serving the Montgomery County communities of Flourtown, Wyndmoor, Erdenheim and Oreland

Springfield Ambulance Association

Privacy Statement (con’t)

•     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 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 that 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   fw' 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.

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 h'ave 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 your PHI. You have the right to request that we restrict how we use   — and disclose your medical information that we have about you. SAA is not required to agree to any restrictions you request, but any restrictions agreed to by SAA in writing are binding on SAA.

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: SAA reserves the right to change the terms of this Notice at any tune, 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 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.

Privacy Officer Contact Information:                    Effective Date of the Notice: April 14,2003

Name:                                                        Gina Bradley/Privacy Officer

Company:                                               Springfield Ambulance Association

Address                                                   8903 Hawthorn Lane Wyndmoor, Pa. 19038

Telephone Number: (215)233-4200                                   E-Mail Address:station311@.comcast.net