OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES
HOW MEDICAL INFORMATION ABOUT
YOU MAY BE USED AND
DISCLOSED AND HOW YOU CAN
ACCESS THIS INFORMATION.
PLEASE REVIEW IT
If you have any questions about this notice, please contact Fire Chief Jeffrey Heaton at: (520) 466-5542, Ext 12 or email firstname.lastname@example.org
Fire Chief Jeffrey Heaton
Arizona City Fire District
P.O. Box 6
Arizona City, Arizona 85123
WHO WILL FOLLOW THIS
This notice describes the information privacy practices followed
by our employees.
YOUR HEALTH INFORMATION
This notice applies to the information and records we have about
your health, health status, and the health care and services you receive from
We are required by law to give you this notice. It will tell you
about the ways in which we may use and disclose health information about you
and describes your rights and our obligations regarding the use and disclosure
of that information.
HOW WE MAY USE AND
DISCLOSE HEALTH INFORMATION ABOUT YOU
We may use health information about you to provide you with
medical treatment or services. We may disclose health information about you to
doctors, nurses, technicians, office staff or other personnel who are involved
in taking care of you and your health.
For example, this includes such things as verbal and written
information that we obtain about you pertaining to your medical condition and
treatment provided to you by us and other medical personnel (including doctors
and nurses who give orders to allow us to provide treatment to you). It also
includes information we give to other health care personnel to whom we transfer
your care and treatment, and includes transfer of medical information via radio
or telephone to the hospital or dispatch center as well as providing the
hospital with a copy of the written record we create in the course of providing
you with treatment and transport.
Different personnel in our office may share information about you
and disclose information to people who do not work in our office in order to
coordinate your care. Family members and other health care providers may be
part of your medical care outside this District and may require information
about you from us.
We may use and disclose health information about you so that the
treatment and services you receive may be billed and payment may be collected
from you, an insurance company or a third party. For example, we may need to
give your health plan information about a service you received here so your
health plan will pay us or reimburse you for the service.
For Health Care
We may use and disclose health information about you in order to
ensure that you and our other patients receive quality care. For example, we
may use your health information to evaluate the performance of our staff in
caring for you. We may also use health information about all or many of our
patients to help us decide what additional services we should offer, how we can
become more efficient, or whether certain new treatments are effective.
We may use or disclose health information about you without your
permission for the following purposes, subject to all applicable legal
requirements and limitations:
To Avert a Serious
Threat to Health or Safety
We may use and disclose health information about you when
necessary to prevent a serious threat to your health and safety or the health
and safety of the public or another person.
Required By Law
We will disclose health information about you when required to do
so by federal, state or local law.
We may use and disclose health information about you for research
projects that are subject to a special approval process. We will ask you for
your permission if the researcher will have access to your name, address or
other information that reveals who you are, or will be involved in your care at
Organ and Tissue
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
donation and transplantation.
National Security and Intelligence
If you are or were a member of the armed forces, or part of the
national security or intelligence communities, we may be required by military
command or other government authorities to release health information about
you. We may also release information about foreign military personnel to the
appropriate foreign military authority.
We may release health information about you for Workers'
Compensation or similar programs. These programs provide benefits for work
related injuries or illness.
Public Health Risks
We may disclose health information about you for public health
reasons in order to prevent or control disease, injury or disability; or report
births, deaths, suspected abuse or neglect, non-accidental physical injuries,
reactions to medications or problems with products.
We may disclose health information to a health oversight agency
for audits, investigations, inspections, or licensing purposes. These
disclosures may be necessary for certain state and federal agencies to monitor
the health care system, government programs, and compliance with civil rights
Lawsuits and Disputes
If you are involved in a lawsuit or a dispute, we may disclose
health information about you in response to a court or administrative order.
Subject to all applicable legal requirements, we may also disclose health
information about you in response to a subpoena.
We may release health information if asked to do so by a law
enforcement official in response to a court order, subpoena, warrant, summons
or similar process, subject to all applicable legal requirements.
Examiners and Funeral Directors
We may release health information to a coroner or medical
examiner. This may be necessary, for example, to identify a deceased person or
determine the cause of death.
We may use or disclose health information about you in a way that
does not personally identify you or reveal who you are.
Family and Friends
We may disclose health information about you to your family
members or friends 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. We may also disclose health information to your family or friends if
we can infer from the circumstances, based on our professional judgment that
you would not object. For example, we may assume you agree to our disclosure of
your personal health information to your spouse when you bring your spouse.
In situations where you are not capable of giving consent, we may,
using our professional judgment, determine that a disclosure to your family
member or friend is in your best interest. In that situation, we will disclose
only health information relevant to the person's involvement in your care. For
example, we may inform the person who accompanied you to the emergency room
that you suffered a heart attack and provide updates on your progress and
OTHER USES AND
DISCLOSURES OF HEALTH INFORMATION
We will not use or disclose your health information for any
purpose other than those identified in the previous sections without your
specific, written Authorization. We
must obtain your Authorization separate
from any Consent we may have obtained
from you. If you give us Authorization to
use or disclose health information about you, you may revoke that Authorization, in writing, at any time.
If you revoke your Authorization, we
will no longer use or disclose information about you for the reasons covered by
your written Authorization, but we
cannot take back any uses or disclosures already made with your permission.
If we have HIV or substance abuse information
about you, we cannot release that information without a special signed, written
authorization (different than the Authorization
and Consent mentioned above) from
you. In order to disclose these types of records for purposes of treatment,
payment or health care operations, we will have to have both your signed Consent and a special written Authorization that
complies with the law governing HIV or substance abuse records.
YOUR RIGHTS REGARDING
HEALTH INFORMATION ABOUT YOU
You have the following rights regarding health information we
maintain about you:
Right to Inspect and
You have the right to inspect and copy your health information,
such as medical and billing records, that we use to make decisions about your
care. You must submit a written request to the Privacy Officer in order to
inspect and/or copy your health information. If you request a copy of the
information, we may charge a fee for the costs of copying, mailing or other
associated supplies. We may deny your request to inspect and/or copy in certain
limited circumstances. If you are denied access to your health information, you
may ask that the denial be reviewed. If such a review is required by law, we
will select a licensed health care professional to review your request and our
denial. The person conducting the review will not be the person who denied your
request, and we will comply with the outcome of the review.
Right to Amend
If you believe health information we have about you is incorrect
or incomplete, you may ask us to amend the information. You have the right to
request an amendment as long as the information is kept by this District.
To request an amendment, complete and submit a Medical Record
Amendment/Correction Form to the Privacy Officer. We may deny your request for an amendment if
it is not in writing or does not include a reason to support the request. In
addition, we may deny your request if you ask us to amend information that:
We did not create, unless the person or entity that created the information is
no longer available to make the amendment.
b) Is not part of the health information that we
c) You would not be permitted to inspect and
d) Is accurate and
complete, to the best of our knowledge.
Right to an Accounting
You have the right to request an "accounting of
disclosures." This is a list of the disclosures we made of medical
information about you for purposes other than treatment, payment and health
care operations. To obtain this list, you must submit your request in writing
to the Privacy Officer. It must
state a time period, which may not be longer than six years and may not include
dates before April 14, 2003. Your request should indicate in what form you want
the list (for example, on paper, electronically). We may charge you for the
costs of providing the list. We will notify you of the cost involved and you
may choose to withdraw or modify your request at that time before any costs are
Right to Request
You have the right to request a restriction or
limitation on the health information we use or disclose about you for treatment,
payment or health care operations. You also have the right to request a limit
on the health information we disclose about you to someone who is involved in
your care or the payment for it, like a family member or friend. For example,
you could ask that we not use or disclose information about a surgery you had.
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.
To request restrictions, you may complete and submit the Request For Restriction
Use/Disclosure Of Medical Information to the Privacy Officer.
to Request Confidential Communications
You have the right to request that we communicate with you about
medical matters in a certain way or at a certain location. For example, you can
ask that we only contact you at work or by mail.
To request confidential communications, you may complete and
submit the Request For Restriction On
Use/Disclosure Of Medical Information And/Or Confidential Communication to the Privacy Officer. We will not ask
you the reason for your request. We will accommodate all reasonable requests.
Your request must specify how or where you wish to be contacted.
Right to a Paper Copy of
You have the right to a paper copy of this notice. You may ask us
to give you a copy of this notice at any time. Even if you have agreed to
receive it electronically, you are still entitled to a paper copy. To obtain
such a copy, contact the Privacy
CHANGES TO THIS NOTICE
We reserve the right to change this notice, and to make the
revised or changed notice effective for medical information we already have
about you as well as any information we receive in the future. We will post a
summary of the current notice in the office with its effective date in the top
right hand corner. You are entitled to a copy of the notice currently in
If you believe your privacy rights have been violated, you may
file a complaint with our office or with the Secretary of the Department of
Health and Human Services. To file a complaint with our office, contact:
Jeffrey Heaton, Fire Chief
Arizona City Fire District
P.O. Box 6
Arizona City, Arizona 85123
(520) 466-5542 Ext 12
You will not be penalized for filing a complaint.