CHETEK AMBULANCE SERVICES NOTICE OF PRIVACY PRACTICES

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.
 
This Notice tells you about the ways in which Chetek Ambulance Services (referred to collectively in this Notice as “we” or “Chetek Ambulance”), may use and disclose your protected health information and your rights concerning your protected health information.  “Protected health information” is information about you, including demographic information, that can reasonably be used to identify you and that relates to your past, present or future physical or mental health or condition, the provision of health care to you or the payment for that care. 

We are required by a federal law, called the Health Insurance Portability and Accountability Act of 1996 (referred to as HIPAA), to provide you with this Notice about your rights and our legal duties and privacy practices with respect to your protected health information.  We must follow the terms of this Notice while it is in effect.  It’s important to note that some of the uses and disclosures described in this Notice may be limited in certain cases by applicable state laws that are more stringent than the federal standards.
 
HOW WE MAY USE AND DISCLOSE YOUR PROTECTED HEALTH INFORMATION
We may use and disclose your protected health information for certain purposes, including for payment, health care operations and treatment, without first obtaining your authorization.  Here are some examples of how Chetek Ambulance may use or disclose your protected health information without your authorization for payment, health care operations and treatment.

• Payment.  “Payment” refers to the activities of Chetek Ambulance in collecting payment for health care services you receive.  For example, we may use your protected health information for billing purposes or to be reimbursed by an insurer that may be responsible for payment. 
  
• Health Care Operations.  “Health Care Operations” refers to the basic business functions necessary to operate our ambulance service.  For example, we may use your protected health information to review the quality of the care and services you receive.
  
• Treatment.  “Treatment” refers to the provision and coordination of health care by a doctor, hospital or other health care provider.  For example, we may disclose your protected health information to your doctors to enable them to provide proper medical care to you.

OTHER PERMITTED OR REQUIRED DISCLOSURES

• As Required by Law.  We must disclose protected health information about you when required to do so by law.
  
• Public Health Activities.  We may disclose protected health information to public health agencies for reasons such as preventing or controlling disease, injury or disability. 
  
• Victims of Abuse, Neglect or Domestic Violence.   We may disclose protected health information about abuse, neglect or domestic violence to government agencies.
  
• Health Oversight Activities.  We may disclose protected health information to government oversight agencies (e.g., U.S. Department of Labor) for activities authorized by law.
  
• Judicial and Administrative Proceedings.  We may disclose protected health information in response to a court or administrative order.  We may also disclose protected health information about you in certain cases in response to a subpoena, discovery request or other lawful process.
  
• Law Enforcement.  We may disclose protected health information under limited circumstances to a law enforcement official in response to a warrant or similar process; to identify or locate a suspect; or to provide information about the victim of a crime.
  
• Coroners, Funeral Directors, Organ Donation.  We may release protected health information to coroners or funeral directors as necessary to allow them to carry out their duties.  We may also disclose protected health information in connection with organ or tissue donation.
  
• Research.  Under certain circumstances, we may disclose protected health information about you for research purposes, provided certain measures have been taken to protect your privacy.
  
• To Avert a Serious Threat to Health or Safety.  We may disclose protected health information about you, with some limitations, when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person.
  
• Special Government Functions.  We may disclose information as required by military authorities or to authorized federal officials for national security and intelligence activities.
  
• Workers’ Compensation.  We may disclose protected health information to the extent necessary to comply with state law for workers’ compensation programs.

OTHER USES OR DISCLOSURES WITH AN AUTHORIZATION
Other uses or disclosures of your protected health information will be made only with your written authorization, unless otherwise permitted or required by law.  You may revoke an authorization at any time, in writing, except to the extent that we have already taken action on the basis of the authorization.

YOUR RIGHTS REGARDING YOUR PROTECTED HEALTH INFORMATION
You have certain rights regarding protected health information that Chetek Ambulance maintains about you. 

• Right To Access Your Protected Health Information.  You have the right to review or obtain copies of your protected health information records, with some limited exceptions.  Your request to review and/or obtain a copy of your protected health information records must be made in writing.  We may charge a fee for the costs of producing, copying and mailing your requested information, but we will tell you the cost in advance.
  
• Right To Amend Your Protected Health Information.  If you feel that protected health information maintained by Chetek Ambulance is incorrect or incomplete, you may request that we amend the information.  Your request must be made in writing and must include the reason you are seeking a change.  We may deny your request if, for example, you ask us to amend information that was not created by Chetek Ambulance or you ask to amend a record that is already accurate and complete.
  If we deny your request to amend, we will notify you in writing.  You then have the right to submit to us a written statement of disagreement with our decision and we have the right to rebut that statement.
  
• Right to an Accounting of Disclosures by Chetek Ambulance.  You have the right to request an accounting of disclosures we have made of your protected health information.  The list will not include our disclosures made for treatment, payment or health care operations, or disclosures made to you or with your authorization.  The list may also exclude certain other disclosures, such as for national security purposes.
  Your request for an accounting of disclosures must be made in writing and must state a time period for which you want an accounting.  This time period may not be longer than six years and may not include dates before April 14, 2003.  The first accounting that you request within a 12-month period will be free.  For additional lists within the same time period, we may charge for providing the accounting, but we will tell you the cost in advance. 
  
• Right To Request Restrictions on the Use and Disclosure of Your Protected Health Information.  You have the right to request that we restrict or limit how we use or disclose your protected health information for treatment, payment or health care operations.  We may not agree to your request.  If we do agree, we will comply with your request unless the information is needed for an emergency.  Your request for a restriction must be made in writing.  In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit how we use or disclose your information, or both; and (3) to whom you want the restrictions to apply.
  
• Right To Receive Confidential Communications.  You have the right to request that we use a certain method to communicate with you or that we send information to a certain location.  Your request to receive confidential communications must be made in writing.  We will accommodate all reasonable requests.  Your request must specify how or where you wish to be contacted.
  
• Right to a Paper Copy of This Notice.  You have a right at any time to request a paper copy of this Notice, even if you had previously agreed to receive an electronic copy. 
  
• Contact Information for Exercising Your Rights.  You may exercise any of the rights described above by contacting the FAS privacy officer at (888) 325–5665.

CHANGES TO THIS NOTICE
We reserve the right to change the terms of this Notice at any time, effective for protected health information that we already have about you as well as any information that we receive in the future.  We will communicate any changes to our notice through subscriber newsletters, direct mail, and/or our website.

COMPLAINTS
If you believe that your privacy rights have been violated, you may file a complaint with us and/or with the Secretary of the Department of Health and Human Services.  

We support your right to protect the privacy of your protected health information.  We will not retaliate against you or penalize you for filing a complaint.