Emergency Medical Services Privacy Policy

Notice of Privacy Practices
April 14, 2003

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED, AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW THIS NOTICE CAREFULLY.

This Notice applies to all records about your care or treatment that have been created by Culver City Fire Department personnel or agents of the Department. Your personal doctor or the hospital at which you receive care may have different policies and a different Notice regarding your health information.

Our Responsibilities
We are required by law to maintain the privacy of your Protected Health Information (PHI) and provide you a description of our privacy practices. We will abide by the terms of this notice.

How We May Use and Disclose Your Protected Health Information (PHI)
Uses and Disclosures That Do Not Require Your Authorization

For Treatment
We may use or disclose your PHI to provide care and treatment to you or in order for others to provide treatment to you. For example, we may disclose your PHI to physicians, nurses and other health care personnel involved in your care and treatment.

For Payment
We may use and disclose PHI about your care to bill and collect payment from you, your insurance company, or a third party for the treatment provided. For example, we may use your PHI to create the bills that we submit to the insurance company, or we may disclose medical information to our business associates who perform billing and claims processing or other services for us. We may also disclose your PHI to another health care provider or insurance company for their payment-related activities.

For Health Care Operations
Fire Department personnel and/or members of our Quality Improvement committee may use information on your health record to evaluate the quality of care and treatment in your case. The results of this evaluation will be used to continually improve the quality of care for all patients we serve. We may also provide your PHI to our attorneys, accountants or other consultants to ensure that we are complying with applicable laws.

Law Enforcement/Legal Proceedings
We may disclose health information for law enforcement purposes as required by law or in response to a valid subpoena or court order.

As Required by Law
The law allows us to disclose PHI without your authorization in the following circumstances, including but not limited to:

• When required to do so by Federal, State or Local laws.
• When issuing mandated reports about victims of abuse, neglect or domestic violence.

The law also allows us to disclose PHI without your authorization to the following types of entities, including but not limited to:

• Public Health or Legal Authorities charged with preventing or controlling disease, injury, or disability.
• Health Oversight Agencies who have authority to audit or investigate our operations.
• Local Emergency Medical Services agencies in connection with their oversight role over our ambulance services.
• Coroners or Medical Examiners in the performance of their duties.
• Organ Procurement Organizations to facilitate organ donation and transplantation.
• Workers Compensation Agencies.
• Correctional Institutions.
• Military Command Authorities.
• National Security and Intelligence agencies.
• Protective Services for the President and others.

Uses and Disclosures That Require Us to Give You the Opportunity to Object

Individuals Involved in Your Care or Payment for Your Care
If you do not object, we may provide relevant portions of your PHI to a family member, friend, or other person you indicate who is involved in your health care or payment thereof. 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. We will give you the opportunity to object to future disclosures to family and friends if possible. In addition, we may also disclose your PHI to entities performing disaster relief activities so that your family can be notified about your condition and location.

Other Uses and Disclosures of Your Protected Health Information (PHI)
Other uses and disclosures of your PHI that are not covered by this Notice, or the laws that may apply to us, will only be made with your written authorization. You may revoke this authorization at any time by submitting a request in writing to our Department Privacy Officer. If you revoke your authorization, we will no longer use or disclose your PHI for the purposes specified in the written authorization. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provided to you.

Business Associates
There are some services provided in our organization through contracts with business associates. For example, we may utilize the services of a medical billing agent to perform billing and claims processing for treatment we have provided. When these services are contracted, we may disclose your PHI to our business associates so that they may perform their necessary job functions. However, to protect your PHI we require the business associates to appropriately safeguard your information.

Your Health Information Rights
You have the following rights related to your health care records maintained by the Culver City Fire Department:

• The Right to Inspect and Copy: Except for very limited circumstances, you have the right to inspect and copy medical information that may be used to make decisions about your care. Requests to inspect must be submitted in writing and addressed to our Department Privacy Officer. In certain situations we may deny your request. If this occurs, you will be notified in writing of the reason for denial and your rights with regard to having the denial reviewed.
• The Right to Amend: If you believe that the PHI we have about you is incomplete or incorrect, you may ask us to amend it. Any request must be submitted in writing and must advise why the amendment is needed. We may deny your request for an amendment. If this occurs, you will be notified in writing of the reason for denial.
• The Right to an Accounting of Disclosures: You have a right to request an accounting of disclosures of your PHI. This is a list of instances in which we have disclosed your PHI for purposes other than: treatment, payment, health care operations, disclosures permitted by our privacy practices or law, for disaster relief or national security purposes, or disclosures to law enforcement. Requests for a list of disclosures must be submitted in writing to our Department Privacy Officer.
• The Right to Request Restrictions: You have the right to request a restriction or limitation on the PHI we use or disclose about you for treatment, payment or health care operations. You also have the right to request a limit on the medical information we disclose to family members or friends involved in your care, or payment of care. Any such request must be submitted in writing to our Departments Privacy Officer. We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment.
• The Right to Request Confidential Communications: You have the right to request that we send information to you at a specific address (for example, work rather that home) or in a specific manner (for example, by e-mail rather than regular mail). We will agree to your request as long as it is not disruptive to our operations. You must make any such request in writing, addressed to our Departments Privacy Officer.
• The Right to a Paper Copy of this Notice: You have the right to request a paper copy of this notice at any time. You may obtain a copy of this Notice by contacting our Privacy Officer at (310) 253-5917.

To exercise any of your rights, please obtain the required forms from our Departments Privacy Officer and submit your request in writing.

Changes to this Notice
We reserve the right to change our privacy practices and to make such changes applicable to the health information we obtained about you before the change, as well as to information we may receive in the future. You may obtain a copy of any revised Notice by contacting our Privacy Officer at (310) 253-5917. We will also make any revised Notice available at this website

Complaints
If you believe your privacy rights have been violated, you may file a complaint with our Department by calling our Privacy Officer at 310-253-5917. Complaints may also be filed with the Secretary of the Department of Health and Human Services. All complaints must be submitted in writing. You will not be penalized for filing a complaint.

If you have any questions about this notice, please contact our Departments Privacy Officer