Stone Bank Fire Department- Patient Privacy and Protected Health Information

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!

Is required by law to maintain the privacy of certain confidential health care information, known as Protected Health Information or PHI, and to provide you with a notice of our legal
duties and privacy practices with respect to your PHI. Stone Bank Volunteer Fire Department is also required to abide by the terms of the version of this Notice currently in effect.

Uses and Disclosures of PHI
Stone Bank Volunteer Fire Department may use PHI for the purposes of treatment, payment, and health care operations, in most cases without your
written permission. Examples of our use of your PHI:

• For Treatment: This includes such things as obtaining verbal and written information about your medical condition and treatment from you as well as from others, such as doctors and nurses who give orders to allow us to provide treatment to you. We may give your PHI to other health care providers involved in your treatment, and may transfer your PHI via radio or telephone to the hospital or dispatch center.
• For Payment: This includes any activities we must undertake in order to reimbursed for the services we provide to you, including such things as submitting bills to insurance companies, making medical necessity determinations and collecting outstanding accounts.
• For Health Care Operations: This includes quality assurance activities, licensing, and training programs to ensure that our personnel meet our standards of care and follow established policies and procedures, as well as certain other management functions.

Use and Disclosure of PHI Without Your Authorization
Stone Bank Volunteer Fire Department is permitted to use PHI without your written authorization, or opportunity to object, in certain situations, and unless prohibited by a more stringent state law including:

• For the treatment, payment or health care operations activities of another health care provider who treats you;
• For health care and legal compliance activities;
• To a family member, other relative, or close personal friend or other individual involved in your care if we obtain your verbal agreement to do so or if we give you an opportunity to object to such disclosure and you do not raise an objection , and in certain other circumstances where we are unable to obtain your agreement and believe the disclosure is in your best interests;
• To a public health authority in certain situations as required by law (such as to report abuse, neglect, or domestic violence);
• For health oversight activities including audits or government investigations, inspections, disciplinary proceedings, and other administrative or judicial actions undertaken by the government (or their contractors) by law to oversee the health care system;
• For judicial and administrative proceedings as required by a court or administrative order, or in some cases in response to a subpoena or other legal process;
• For law enforcement activities in limited situations, (i.e.: responding to a warrant);
• For military, national defense and security and other special government functions;
• To avert a serious threat to the health and safety of a person of the public at large;
• For workers’ compensation purposes, and in compliance with workers’ compensation laws;
• To coroners, medical examiners, and funeral directors for identifying a deceased
  person, determining cause of death, or carrying on their duties as authorized by law;
• 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 such action;
• 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 that 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 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. We are permitted by law to deny your request to amend medical information, only in certain circumstances (i.e.: if we believe the information you are asking to be amended is correct). To request an amendment, contact our Privacy officer.
• The right to request an accounting. You may request an accounting from us of certain disclosures of medical information that we may have made in the six years prior to the date of your request. We are not required to give you an accounting of information used for treatment, payment or health care operations, or those which you have already given us written authorization for. If you need an accounting, contact our privacy officer.
• The right to request that we restrict the uses and disclosures of your PHI, however, the Stone Bank Volunteer Fire Department is not required to agree to any restrictions you request.
• The right to request a paper copy of Notice. Revisions to the Notice, can be made by Stone Bank Volunteer Fire Department at any time, and a copy of the latest version can be obtained from 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 in any way for filing a complaint with us or the government. Should you have any questions, comments or complaints, you may direct all inquiries to our privacy officer.

Privacy Officer Contact Information:
Captain Sue Simons
Privacy Officer
W335 N7107 Stone Bank Road
Oconomowoc, WI 53066
Phone: 262-966-2414
Fax: 262-966-2831

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