FOREST VIEW VOLUNTEER RESCUE SQUAD, INC.

Please below for our Patient Privacy Policy, Business Privacy Policy, and Business Terms and Conditions

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.

Emergency Medical Service agencies are 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 the legal duties and privacy practices with respect to your PHI. This Notice is being provided to you on behalf of the EMS agencies operating in Chesterfield County, including both the Chesterfield Fire and EMS Department (“CFEMS”) and volunteer rescue squads operating in Chesterfield (CFEMS and the rescue squads are the “Chesterfield EMS Agencies”). The Chesterfield EMS Agencies are required to abide by the terms of the version of this Notice currently in effect.

Effective Date of the Notice: Sept. 1, 2013

Use and Disclosures of Protected Health Information

The Chesterfield EMS Agencies may use protected health information (PHI) for the purposes of treatment, payment and health care operations, in most cases without your written permission.

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 get 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.

Fundraising

We may contact you when we are in the process of raising funds for any of the Chesterfield EMS Agencies, or to provide you with information about the CFEMS annual subscription program called EMS Passport. You may choose to “opt out” of receiving fundraising notices by contacting the Privacy Officer.

Use and Disclosure of PHI Without Your Permission

The Chesterfield EMS Agencies are 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
• As required by law, including reporting for public health purposes
• 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 a 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 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, discovery request, or other legal process
• For law enforcement activities in limited situations, such as when 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 or 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 organ donation and transplantation
• 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 (such as those made for marketing purposes), other than those listed above, will be made only 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 protected health information (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 if you disagree with our decision, you may obtain a review of certain types of denials.

We have forms available to request access to your PHI. We will provide a written response if we deny you access and let you know your review rights. You also have the right to receive confidential communications of your PHI. To assure your records are discussed and disclosed only to the proper person (you or your legally authorized representative), we normally require you to appear in person at our office to access or discuss your medical information. However, we will honor reasonable requests by you to receive communications about your medical information by alternative means or at alternative locations. If you wish to inspect and copy your medical information, you should contact our Privacy Officer, whose address and phone number is listed below.

The Right to Amend Your PHI

You have the right to ask us to amend written medical information that we may have about you if you think it is inaccurate or incomplete. We will generally amend your information within 60 days of your request and will notify you when we have amended the information. We are permitted by law to deny your request to amend your medical information only in certain circumstances, like when we believe the information you have asked us to amend is correct and complete. If you wish to request that we amend the medical information that we have about you, you should contact our Privacy Officer.

The Right to Request an Accounting

We are required to keep a record of certain disclosures of your medical information, and you may request an accounting of what that record contains. Disclosures that we are not required to keep a record of include:

• Information we have used or disclosed for purposes of treatment, payment or health care operations.
• When we share your health information with our business associates, like our billing company or a medical facility from or to which we have transported you.
• Information for which you have already given us written authorization to disclose.

We are required to keep this record of disclosures for six years. If you wish to request an accounting of these disclosures, contact our Privacy Officer.

The Right to Request That We Restrict the Uses and Disclosures of Your PHI

You have the right to request that we restrict how we use and disclose the medical information that we have about you. The Chesterfield EMS Agencies are required to agree to your request to restrict disclosure of your PHI to a health insurance company if the disclosure is for payment or health care operations and is for a service (such as ambulance transportation) for which you have paid out of pocket in full. The Chesterfield EMS Agencies are not required to agree to other restrictions you request, but any restrictions agreed to by us in writing are binding on us. You must contact the Privacy Officer to request a restriction.

The Right to Be Notified of a Breach

You have the right to be notified in the event that we (or one of our business associates) discover a breach of unsecured PHI. Internet, Electronic Mail, and the Right to Obtain Copy of Paper Notice on Request: CFEMS will prominently post a copy of this Notice on its website. If the other Chesterfield EMS Agencies maintain websites, they will prominently post a copy of this Notice on their websites or include a link to the CFEMS website on their page. If you allow us, we will forward you this Notice by electronic mail instead of on paper and you may always request a paper copy of the Notice.

Revisions to the Notice

The Chesterfield EMS Agencies reserve the right to change the terms of this Notice at any time, and the changes will be effective immediately and will apply to all protected health information that we maintain. Any material changes to the Notice will be promptly posted on the CFEMS website and the websites of the other Chesterfield EMS Agencies, if they maintain one. You can get a copy of the latest version of this Notice by contacting 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 against in any way for filing a complaint with us or to the government. Should you have any questions, comments, or complaints, you may direct them to our Privacy Officer.