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
Your health information is personal, and Superior Air-Ground Ambulance Service, Inc., Superior Air-Ground Ambulance Service of Indiana, Inc., Superior Air-Ground Ambulance Service of Michigan, Inc. and Superior Air Ambulance Service, Inc. (collectively Superior Ambulance Service) is committed to protecting it. We are required by law to maintain the privacy of your protected health information (PHI) that could be used to identify you. The law also requires us to provide you with a copy of this Notice of Privacy Practices (Notice), which describes our privacy practices and our legal duties with respect to PHI. Under certain circumstances, we may also be required to notify you following a breach of unsecured PHI.
HOW WE MAY USE OR DISLCOSURE YOUR PHI WITHOUT YOUR AUTHORIZATION
Treatment. We may use or disclose your PHI in connection with our treatment or transportation of you. For example, we may disclose your PHI to doctors, nurses, technicians, medical students or any other health care professional involved in taking care of you. We may also provide information about you to a hospital or dispatch center via radio, telephone or other electronic means. We may provide a hospital or other health care facility with a copy of the medical records created by us in the course of treating or transporting you.
Payment. We may use and disclose your medical information to obtain payment from you, an insurance company or other third parties. For example, we may provide PHI to your health insurance plan in order to receive payment for our services. We may also contact your insurance plan to confirm your coverage or to request prior approval for a planned service. We also may disclose your medical information to your insurer or another health care provider for their payment activities. Lastly, we may provide your PHI to other companies or individuals that need the information to provide services to us. These other entities, known as "business associates," are required to maintain the privacy and security of PHI. For example, we may use an outside collection agency to obtain payment when necessary.
Health care operations. We may use and disclose your PHI for quality assurance activities, licensing and training programs to ensure that our personnel meet our standards for care, and to ensure that our personnel follow our established policies and procedures. We may also use your information for obtaining legal, financial or accounting services, conducting business planning, processing complaints, and for the creation of reports that do not individually identify you.
Other uses or disclosures that do not require your authorization. The law permits us to use or disclose your PHI without your authorization in the following circumstances:
USES OR DISCLOSURES WHERE YOU HAVE THE RIGHT TO OBJECT
Unless you object, we may provide relevant portions of your PHI to a family member, friend or other person that you indicate is involved in making decisions about your health care, or in paying for your health care. We may use or disclose PHI to notify your family member, friends or personal representative about your condition. In an emergency or when you are not capable of agreeing or objecting to these disclosures, we will disclose your PHI only to the extent we reasonably believe such disclosure to be in your best interest, and we will tell you about such disclosure after the emergency has passed, and give you the opportunity to object to future disclosures to family, friends or personal representatives. Unless you object, we may also disclose your PHI to persons involved in providing disaster relief, for example, the American Red Cross.
USES OR DISCLOSURES THAT REQUIRE YOUR WRITTEN CONSENT
Any other use or disclosure of PHI, other than those listed above will only be made with your written authorization. The law also requires your written authorization before we may use or disclose: (i) psychotherapy notes, other than for the purpose of carrying out our treatment, payment or health care operations purposes, (ii) any PHI for our marketing purposes or (iii) any PHI as part of a sale of PHI. You may request to revoke a previous written authorization in writing at any time by sending the request to Privacy Officer.
YOUR RIGHTS WITH RESPECT TO YOUR PHI
You have the following rights with respect to your PHI:
NOTIFICATION IN THE EVENT OF AN UNAUTHORIZED USE OR DISCLOSURE
The law may require us to notify you in the event of an unauthorized use or disclosure of your unsecured PHI. To the extent we are required to notify you, we must do so no later than 60 days following our discovery of such unauthorized use or disclosure. This notification will be made by first class mail or email (if you have indicated a preference to be notified by email), and must contain the following information:
CHANGES TO THIS NOTICE
Superior Ambulance Service is required to comply with the terms of this Notice as currently in effect. We reserve the right to change or amend our privacy practices at any time in the future, and to make any changes applicable to PHI already in our possession. This Notice will be revised to reflect any changes in our privacy practices. You may obtain a copy of our revised Notice by contacting our Privacy Officer. We will also make any revised Notice available on our website at www.superiorambulance.com
If you should have questions or comments about our privacy practices, or if you would like to obtain additional information regarding your privacy rights, please contact our Privacy Officer at:
Superior Ambulance Service, Inc.
Attn: Privacy Officer
395 W. Lake St.
Elmhurst, IL 60126
If you believe that your privacy rights have been violated, you may file a complaint with Superior Ambulance Service, Inc. or with the Secretary of the Department of Health and Human Services (DHHS). To file a complaint with us, please put your complaint in writing and mail it or email it to the following address:
Superior Ambulance Service
Attn: Privacy Officer
395 W. Lake St.
Elmhurst, IL 60126
To file a complaint with the DHHS, you must put your complaint in writing and mail it to:
Office for Civil Rights
U.S. Department of Health and Human Services
200 Independence Avenue, S.W.
Washington, D.C. 20201.
You will not be retaliated against or denied any health services if you elect to file a complaint.
Effective Date: April 2003
Revision Date: May 2016