Southborough
Fire Department
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 we are committed to protecting it. Your health information is also
very important to our ability to provide you with quality care, and to comply
with certain laws. This Notice
applies to all records about care provided to you by Southborough Fire
Department. (Your physician may
have different policies and a different notice regarding your health information
that is created in the physician’s office.
I.
We Are Legally Required to Safeguard Your Protected Health information.
We
are required by law to:
A.
maintain the privacy of your health information, also known as
“protected information” or
“PHI” .
B.
provide you with this Notice, and
C.
comply with this notice.
II.
Future Changes to Our Practice and This Notice.
We reserve the right to
change our privacy practices and to make any such change applicable to the PHI
we obtain about you previously. If
a change in our practices is material, we will revise this Notice to reflect the
change. You may obtain a copy of
any revised Notice by contacting the Ethics & Compliance Department at
888-828-7284. We will also make any
revised Notice available on our web site at SouthboroughFire.org.
III.
How We May Use and Disclose Your Protected Health Information.
The law requires us to have
your authorization for some uses and disclosures. In other circumstances, the law allows us to use or disclose
PHI without your authorization. This
section gives examples of each of these circumstances.
Uses and Disclosures that
Require Us to Give You the Opportunity to Object. Unless you object,
we may provide relevant portions of your PHI to a family member, friend or other
person you indicate is involved in your health care or in helping you get
payment for your health care. We
may use or disclose your PHI to notify your family or personal
representative of your location or condition.
In an emergency or when you are not capable of agreeing or objecting to
these disclosures, we will disclose PHI as we determine is in your best
interest, but will tell you about it later, after the emergency, and give you
the opportunity to object to future disclosures to family and friends.
Unless you object, we may also disclose your PHI to persons performing
disaster relief activities.
A.
Certain Uses and Disclosures Do
Not Require Your Authorization.
The law allows us to disclose PHI without your authorization in the
following circumstances:
(1)
When required by Law.
(2)
For Public Health
Activities.
(3)
For Reports About Victims of
Abuse, Neglect or Domestic Violence.
(4)
To Health Oversight
Agencies.
(5)
For Lawsuits and disputes.
(6)
To Law Enforcement. We may release PHI if asked to do so by a law enforcement
official, in the following circumstances: (a)
in response to a court
order, subpoena, warrant, summons or similar process; (b) to identify or locate
a suspect, fugitive, material witness or missing person; (c) about the victim of
a crime if, under certain limited circumstances, we are unable to obtain the
person’s agreement; (d) about a death we believe is due to criminal conduct;
(e) about criminal conduct at our facility; and (f) in emergency circumstances,
to report a crime, its location or victims, or the identity, description or
location of the person who committed the crime.
(7)
To Coroners, Medical
Examiners and Funeral Directors.
(8)
To Organ Procurement
Organizations.
(9)
For Medical Research.
We may disclose your PHI without your
authorization to medical researchers who request it for approved medical
research projects.
(10)
To Avert a Serious
Threat to Health and Safety.
(11)
For Specialized
Government Functions.
(12)
To Workers’
Compensation or Similar Programs.
IV.
Other Uses and Disclosures of Your Protected Health Information.
Other uses and disclosures
of your PHI that are not covered by this Notice or the laws that apply to us
will be made only with your written authorization.
If you give us written authorization for a use or disclosure of your PHI,
you may revoke that authorization, in writing at any time.
If you revoke your authorization we will no longer use or disclose your
PHI for the purposes specified in the written authorization, except that we are
unable to retract any disclosures we have already made with your permission.
In addition, we can use or disclose your PHI after you have revoked your
authorization for actions we have already taken in reliance on your
authorization. We are also required
to retain certain records of the uses and disclosures made when the
authorization was in effect.
V.
Your Rights Related to Your Protected Health Information.
You
have the following rights:
A.
The Right to Request Limits on
Uses and Disclosures of Your PHI. You have the right to ask
us to limit how we use and disclose your PHI.
Any such request must be submitted in writing to our Policy Officer.
We are not required to agree to your request.
If we do agree, we will put it in writing and will abide by the agreement
except when you require emergency treatment.
B.
The Right to Choose How We
Communicate With You.
You have the right to ask that we send information to you at a specific
address (for example, at work rather than at home) or in a specific manner (for
example, by email rather than by regular mail, or never by telephone.)
We must agree to your request as long as it would not be disruptive to
our operations to do so. You must
make any such request in writing, addressed to our Privacy Officer.
C.
The Right to See and Copy Your
PHI.
Except for limited circumstances, you may look at and copy your PHI if
you ask in writing to do so. Any
such request must be addressed to our Patient Billing Service Center, which will
respond to your request within 10 days (or 30 days if the extra time is needed).
In certain situations, we may deny your request, but if we do, we will
tell you in writing of the reasons for the denial and explain your rights with
regard to having the denial reviewed.
D.
The Right to Correct or Update
Your PHI.
If you believe that the PHI we have about you is incomplete or incorrect,
you may ask us to amend it. Any
such request must be made in writing and must be addressed to our Patient
Billing Service Center, and must tell us why you think the amendment is
appropriate. We will not process
your request if it is not in writing or does not tell us why you think the
amendment is appropriate. We will act on your request within 30 days or less if state
law requires (or 60 days if extra time is needed), and will inform you in
writing as to whether the amendment will be made or denied. If we agree to make the amendment, we will ask you who else
you would like us to notify of the amendment.
We may deny your request if you ask us to amend information that:
(1)
was not created by us, unless the person who created the information is
no longer available to make the amendment;
(2)
is not part of the PHI we keep about you;
(3)
is not part of the PHI that you would be allowed to see or copy; or
(4)
is determined by us to be accurate and complete.
If
we deny the requested amendment, we will tell you in writing how to submit a
statement of
disagreement or complaint, or to request inclusion of your original
amendment request in your PHI.
E.
The Right to Get a List of the
disclosures We Have Made.
You have the right to get a list of instances in which we have disclosed
your PHI. The list will not include
disclosures we have made for our treatment, payment and health care operations
purposes, those made directly to you or your family or friends or through our
facility directory or for disaster relief purposes.
Neither will the list include disclosures made for national security
purposes or to law enforcement personnel, or disclosures made before April 14,
2003.
Your
request for a list of disclosures must be made in writing and be addressed to
the Patient Billing Service Center address that is listed on your invoice.
We will respond to your request within 30 days, or less if state law
requires ( or 60 days if the extra time is needed).
The list we provide will include disclosures made within the last six
years unless you specify a shorter period.
The first list you request within a 12-month period will be free.
You will be charged our costs for providing any additional lists with the
12-month period.
F.
The Right to Get a Paper Copy of
This Notice.
Even if you have agreed to receive the Notice by e-mail, you have the
right to request a paper copy as well. You
may obtain a paper copy of this Notice by contacting the Ethics & Compliance
Department at 888-828-7284. This
Notice is also available on-line at SouthboroughFire.org
VI.
Complaints.
If you believe your privacy
rights have been violated, you may file a complaint with us or with the
Secretary of the Federal Department of Health and Human Services.
To file a complaint with the DHHS put your complaint in writing and
address it to the U.S. Department of Health & Human Services, 200
Independence Ave. SW, Washington, DC, 20201.
Or call them at telephone number
To file a complaint with us, put your complaint in writing and address it
to our Privacy Officer at Southborough Fire Department 21 Main Street
Southborough, Ma 01772. We will not retaliate against you for filing a complaint.
You may also contact our Privacy officer if you have any questions or
comments about our privacy practices.
October 28, 2003