HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT – PROVIDER NOTICE OF PRIVACY PRACTICES

This notice describes how medical information about you may be used and disclosed by American Ambulance Service and how you can get access to this information.

Effective April 14, 2003 Please review it carefully

Uses and disclosures of health information:

We use health information about you for treatment (diagnostic testing, prescription, referral, etc.) to obtain payment (submit claims and/or encounters to billing services and/or clearinghouses, and/or collection agencies, etc.) for administrative purposes (reporting utilization management, quality improvement and surveys, etc) and to evaluate the quality of care that you receive. We may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you.

We may use or disclose identifiable health information about you without your authorization for several other reasons. Subject to certain requirements, we may give out health information without your authorization for public health purposes, for auditing purposes, for research studies, and for emergencies. We provide information when otherwise required by law, such as for law enforcement in specific circumstances. In any other situation, we will ask for your written authorization before using or disclosing any identifiable health information about you. If you choose to sign an authorization to disclose information, you can later revoke that authorization to stop any future uses and disclosures.

We may apply a change to our policies at any time. Before we make a significant change in our policies, we will change our notice and post the new notice in the waiting area and in each ambulance. You may also request a copy of our notice at any time. For more information about our privacy practices, contact the Privacy Officer listed below.

Individual Rights:

You have the right, following a written request and agreed upon date and time, to look at, get a copy of or receive electronically protected health information about you that we use to make decisions about you. If you request copies, we will charge you at our cost for each page. You also have the right to receive a list of instances where we have disclosed protected health information about you for reason other than treatment, payment or related administrative purposes. If you believe that information in your record is incorrect or if important information is missing, you have the right to request in writing that we amend the existing information.

You may request in writing that we restrict and/or not use or disclose your information for treatment, payment and administrative purposes except when specifically authorized by you, when required by law, or in emergency circumstances. We will consider your request but are not legally required to agree to it.

Complaints:

If you are concerned that we have violated your privacy rights, or you disagree with a decision we made about access or amendment to your records, you may contact the Privacy Officer listed below. You may send a written complaint to the U.S. Department of Health and Human Services, Office of Civil Rights. The Privacy Officer listed below can provide you with the appropriate address upon request.

Our Legal Duty:

We are required by law to protect the privacy of your information, provide this notice about our information practices, and follow the information practices that are described in this notice.

Questions or complaints may be address to:

Falck USA
21540 30th Dr SE, # 250
Bothell, WA 98021
Privacy Officer: Brian Richmond