including Huron Valley Ambulance and Jackson Community Ambulance

Our ambulance service is required by law to maintain the privacy of certain health information, known as Protected Health Information (“PHI”). This brochure provides you with notice of our legal duties and privacy practices with respect to your PHI. We are required to abide by the terms of the version of the Notice that is currently in effect.

We are permitted or required to use your PHI without your written authorization, or an opportunity to object, in certain circumstances, including:

• For Treatment: This includes such things as obtaining verbal and written information about your medical condition and treatment from you, as well as others, such as doctors and nurses who give us treatment orders. We may give your PHI to other health care providers involved in your treatment.

• 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, procedures and certain other management functions.

• For Health Care Oversight and legal compliance activities, including audits or government investigations, disciplinary proceedings and other administrative or judicial actions undertaken by the government (or contractors) by law.

• To public health authorities in certain situations as required by law (such as to report abuse, neglect or domestic violence).

• For Judicial and administrative proceedings as required by a court or administrative order, or in response to a subpoena or other legal process.

• For Law Enforcement: in certain limited circumstances, such as with warrants or where information is needed to locate or respond to a crime or to apprehend an individual who participated in a violent crime or escapee from lawful custody.

• Serious threat to Health of Safety: to prevent or lessen the imminent threat of a person or the public in accordance with federal or state law.

• Military Activity/National Security: for certain limited functions or other special government functions.

• Organ Donation: If you are an organ donor, to organizations that handle organ procurement/transplantation as necessary to facilitate organ donation and transplantation.

• Medical Examiner and Funeral Directors: for identifying a deceased person, determining cause of death, or funeral home activities.

• Research: we may use and disclose your PHI to researchers when an institutional review board has reviewed the research proposal and protocols to ensure the privacy of your PHI, and has approved the research.

• Workers Compensation: to comply with workers compensation laws and other similar legally established programs.

• De-Identified Information: We may use and disclose your PHI if it does not personally identify you or reveal who you are.

Any other use or disclosure of PHI other than those listed above will only be made with your written authorization, which you may revoke at any time, in writing, except to the extent that we have already used or disclosed PHI in reliance on that authorization.

You will be given an opportunity to agree or object before we use or disclose your PHI for the following purposes.

However, in emergency circumstances or if you are incapacitated, our staff, in their professional judgment, will determine whether the use or disclosure is in your best interest. Our staff will then release only PHI directly relevant to that person’s involvement in your health care:

Access, Inspection and Copying of Your PHI: You have the right to inspect and copy your PHI that is contained in a designated record set of medical and billing records for as long as we maintain it. In certain circumstances, we may deny your access to PHI, and you may appeal certain types of denials. You must complete a form to request access or copies, and normally we will provide you with access or copies within 30 days. A reasonable fee will be applied for copying. If you wish to inspect and/or copy your PHI, contact our Privacy Officer (designated at the end of this notice). You also have the right to receive confidential communications of your PHI.

Your Right to Amend Your PHI: You have the right to ask us to amend your PHI. We have the right to deny your request if we believe the PHI is correct. If we deny the request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal statement. You will need to complete a request form to amend your PHI which is available from our Privacy Officer. Normally, we will respond to your request to amend within 60 days.

Right To Request A Restriction of the Use or Disclosure of your PHI. You have the right to ask us to restrict the use and disclosure of your PHI for the purpose of treatment, payment, and health care operations. You may also request that your PHI not be disclosed to family members or friends who may be involved in your care. We have the right to deny your request for a restrictions in emergency circumstances. You will need to complete a form to request these restrictions which is available from our Privacy Officer.

Right to Receive An Accounting of Disclosures We have Made of your PHI. You may ask for an accounting from us of certain disclosures of your PHI that we have made after April 14, 2003, with within the last six years prior to your request. We are not required by law to account for certain disclosures, such as for treatment, payment or operations, or disclosures pursuant to your written authorization. If you wish to request an accounting of disclosures that are not exempted, contact our Privacy Officer.

Right To Obtain A Paper Copy Of Notice of Privacy Practices. You have the right to obtain a paper copy of this Notice of Privacy Practices. Please contact our Privacy Officer.

You have the right to complain to us, or to the Secretary of the U.S. Department of Health and Human Services, if you believe your privacy rights have been violated. We will not retaliate against you in any way for filing a complaint with the government or us. You may file a complaint with our Privacy Officer who will give you further information about the Complaint Process.

We 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 PHI that we maintain. Any material changes to the Notice will be promptly posted on our web site. You may obtain a copy of the latest version by contacting our Privacy Officer.

If you have any questions about this Notice, your rights with respect to PHI, or if you wish to file a complaint, please contact:

Lenawee Community Ambulance

(including Huron Valley Ambulance and Jackson Community Ambulance)

2215 Hogback Road, Ann Arbor, Michigan  48105

734-477-6339