insurer, HMO, or other company that arranges or pays the cost of some or all of your health care to verify that your health plan will pay for the health care.  We may also share insurance information with other medical providers (such as Emergency Department physicians, pathologists, radiologists, etc.) who provided you care but are independent contractors and, therefore, not employed by us.

·        Health Care Operations.  We may use and disclose your PHI for our health care operations, which include internal administration and planning and various activities that improve the quality and cost effectiveness of the care that we deliver to you.  For example, we may use PHI to evaluate the quality and competence of our staff and other health care workers.  We may also disclose information to doctors, nurses, technicians, medical, nursing and other students, interns and residents, volunteers, and other personnel for teaching purposes.  We may disclose PHI to our Patient Representatives in order to resolve any complaints you may have and ensure that you have been well treated by us. 

We may also disclose PHI to another health care facility or home health provider to which you have been transferred, when such PHI is required for them to treat you, receive payment for services they render to you, or conduct certain health care operations, such as quality assessment and improvement activities, reviewing the quality and competence of health care professionals, or for health care fraud and abuse detection or compliance.

      Use or Disclosure for Directory of Individuals our Directory.  As we are not an in-patient facility, we do not maintain a patient directory. Thus, we will not use or disclose your PHI for use in a directory.

      Disclosure to Relatives, Close Friends and Other Caregivers.  We may use or disclose your PHI to a family member, other relative, a close personal friend or any other person identified by you when you are present for, or otherwise available prior to, the disclosure, if we:

• obtain your agreement;


• provide you with the opportunity to object to the disclosure and you do not object; or


• reasonably infer that you do not object to the disclosure

If you are not present, or the opportunity to agree or object to a use or disclosure cannot practicably be provided because of your incapacity or an emergency circumstance, we may exercise our professional judgment to determine whether a disclosure is in your best interests.  If we disclose information to a family member, other relative or a close personal friend, we would disclose only information that we believe is directly relevant to the person's involvement with your health care or payment related to your health care.  When relatives, close friends and other caregivers request disclosure of your PHI via a distant means (e.g., telephone, internet, etc.) we will comply with our information security and privacy policies concerning distant inquiries.  We may also disclose your PHI in order to notify (or assist in notifying) such persons of your location, general condition or death.

      Public Health Activities.  We may disclose your PHI for the following public health activities: 

• to report health information to public health authorities for the purpose of preventing or controlling disease, injury or disability;
• to report child abuse and neglect to public health authorities or other government authorities authorized by law to receive such reports;
• to report information about products and services under the jurisdiction of the U.S. Food and Drug Administration;
• to alert a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading a disease or condition; and
• to report information to your employer as required under laws addressing work-related illnesses and injuries or workplace medical surveillance. 

      Victims of Abuse, Neglect or Domestic Violence.  If we reasonably believe you are a victim of abuse, neglect or domestic violence, we may disclose your PHI to a governmental authority, including a social service or protective services agencies, authorized by law to receive reports of such abuse, neglect, or domestic violence.

      Health Oversight Activities.  We may disclose your PHI to a health oversight agency that oversees the health care system and is charged with responsibility for ensuring compliance with the rules of government health programs such as Medicare or Medicaid. 

      Judicial and Administrative Proceedings.  We may disclose your PHI in the course of a judicial or administrative proceeding in response to a legal order or other lawful process, such as, under Virginia state law, the request of a person (or his/her insurance carrier) against whom you have commenced a lawsuit for compensation or damages for your personal injuries.

      Law Enforcement Officials.  We may disclose your PHI to the police or other law enforcement officials as required or permitted by law or in compliance with a court order or a grand jury or administrative subpoena. 

      Decedents.  We may disclose your PHI to a coroner or medical examiner as authorized by law.  This may be necessary, for example, to identify a deceased person or determine the cause of death.  We may also release medical information about our patients to a funeral director as necessary to carry out their duties.

      Organ and Tissue Procurement.  If you are or become an organ donor, we may disclose your PHI to organizations that facilitate organ, eye or tissue procurement, banking or transplantation. 

      Research. We may use or disclose your PHI without your consent or authorization if our Committee for the Protection of Human Subjects in Research approves a waiver of authorization for disclosure.

      Health or Safety.  We may use or disclose your PHI to prevent or lessen a threat of imminent, serious physical violence against you or another readily identifiable individual or if there is a threat to the general public. 

      Specialized Government Functions.  We may use and disclose your PHI to units of the government with special functions, such as the U.S. military or the U.S. Department of State under certain circumstances.

      Workers' Compensation.  We may disclose your PHI as authorized by and to the extent necessary to comply with state law relating to workers' compensation or other similar programs. 

      Military and Veterans.  We may release medical information about you as required by military command authorities if you are a member of the armed forces.  We may also release medical information about foreign military personnel to the appropriate foreign military authority.

      National Security and Intelligence Activities.  We may release medical information about you to authorized federal officials for intelligence, counter-intelligence, and other national security activities authorized by law.

      Protective Services for the President and Others.  We may disclose medical information about you to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state or conduct special investigations. 

      Inmates.  If you are an inmate of a correctional institution or in the custody of a law enforcement official, we may release medical information about you to the correctional institution or law enforcement official.  This release would be necessary:

• for the institution to provide you with health care;


• to protect your health and safety or the health and safety of others; or


• for the safety and security of the correctional institution.

      As required by law.  We may use and disclose your PHI when required to do so by any other law or regulation not already referred to above.

USES and DISCLOSURES REQUIRING YOUR WRITTEN AUTHORIZATION

      Use or Disclosure with Your Authorization:  For any purpose other than the ones described above, we only may use or disclose your PHI when you grant us your written authorization on our authorization form ("Your Authorization").  For instance, you will need to execute an authorization form before we can send your PHI to your life insurance company or to the attorney representing the other party in litigation in which you are involved. 

      Marketing.  We do not use or share medical information for marketing purposes.  If you receive marketing materials from us, it is because we have received your contact information from another source, such as a zip code listing.  We must also obtain your written authorization prior to using your PHI to send you any marketing materials.  (We can, however, provide you with marketing materials in a face-to-face encounter without obtaining authorization.)  In addition, we may communicate with you about products or services relating to your treatment, case management or care coordination, or alternative treatments, therapies, providers or care settings without your authorization.

      HIV/AIDS Related Information.  Your authorization must expressly refer to your HIV/AIDS related information in order to permit us to disclose your HIV/AIDS related information.  However, there are certain purposes for which we may disclose your HIV/AIDS information, without obtaining your authorization: 

• your diagnosis and treatment;
• scientific research;
• management audits, financial audits or program evaluation;
• medical education;
• disease prevention and control when permitted by the New Jersey Department of Health and Senior Services;
• to comply with a certain type of court order; and
• when required by law, to the Department of Health and Senior Services or another entity. 

You also should note that we may disclose your HIV/AIDS related information to third party payers (such as your insurance company or HMO) in order to receive payment for the services we provide to you.

      Genetic Information.  Except in certain cases (such as a paternity test for a court proceeding, anonymous research, newborn screening requirements, or pursuant to a court order), we will obtain your special written consent prior to obtaining or retaining your genetic information (for example, your DNA karyotype), or using or disclosing your genetic information for treatment, payment or health care operations purposes.  We may use or disclose your genetic information for any other reason only when your authorization expressly refers to your genetic information or when disclosure is permitted under Virginia State law (including, for example, when disclosure is necessary for the purposes of a criminal investigation, to determine paternity, newborn screening, identifying your body or as otherwise authorized by a court order).

      Sexually Transmitted Disease Information.  Your authorization must expressly refer to your sexually transmitted disease information in order to permit us to disclose any information identifying you as having or being suspected of having a sexually transmitted disease.  However, there are certain purposes for which we may disclose your sexually transmitted disease information, without obtaining your authorization including:

• to a prosecuting officer or the court if you are being prosecuted under Virginia State law,


• to the Virginia State Department of Health (modify as appropriate), or


• to your physician or a health authority, such as the local board of health.

Your physician or a health authority may further disclose your sexually transmitted disease information if he/she/it deems it necessary in order to protect the health or welfare of you, your family or the public.  Under Virginia State law, we may also grant access to your sexually transmitted disease information upon the request of a person (or his/her insurance carrier) against whom you have commenced a lawsuit for compensation or damages for your personal injuries. (modify as appropriate)

      Tuberculosis Information.  Your authorization must expressly refer to your tuberculosis information in order to permit us to disclose any information identifying you as having tuberculosis or refusing/failing to submit to a tuberculosis test if you are suspected of having tuberculosis or are in close contact to a person with tuberculosis.  However, there are certain purposes for which we may disclose your tuberculosis information, without obtaining your authorization, including for research purposes under certain conditions, pursuant to a valid court order, or when the Commissioner of the Virginia State Department of Health (or his/her designee) (Modify as appropriate) determines that such disclosure is necessary to enforce public health laws or to protect the life or health of a named person.

      Psychotherapy Notes.         We will obtain your authorization to disclose any psychotherapy notes as defined by law about you except under certain circumstances as permitted by regulation.

YOUR RIGHTS REGARDING YOUR PROTECTED HEALTH INFORMATION

      Right to Request Additional Restrictions.  You may request restrictions on our use and disclosure of your PHI:

• for treatment, payment and health care operations,
• to individuals (such as a family member, other relative, close personal friend or any other person identified by you) involved with your care or with payment related to your care, or
• to notify or assist in the notification of such individuals regarding your location and general condition. 

While we will consider all requests for additional restrictions carefully, we are not required to agree to a requested restriction.  If you wish to request additional restrictions, please obtain a request form from our Privacy Office and submit the completed form to the Privacy Office.  We will send you a written response within thirty (30) days.

      Right to Receive Confidential Communications.  You may request, and we will accommodate, any reasonable written request for you to receive your PHI by alternative means of communication or at alternative locations.

      Right to Revoke Your Authorization.  You may revoke your authorization  except to the extent that we have taken action in reliance upon it, by delivering a written revocation statement to the Privacy Office identified below.  A form of Written Revocation is available upon request from the Privacy Officer.

      Right to Inspect and Copy Your Health Information.  You may request access to your medical record file and billing records maintained by us in order to inspect and request copies of the records.  Under limited circumstances, we may deny you access to a portion of your records.  We will comply with the law if the physician says that review of any record would be harmful to your best interest.  For example, we may withhold certain portions of a psychiatric record if the physician or psychologist believes that such review of the complete record would be harmful to your best interest

If you desire access to your medical records, please obtain a record request form from our offices and submit the completed form to us.  We may charge you a reasonable copying fee in accordance with Virginia State law.   

You should take note that if you are a parent or legal guardian of a minor, certain portions of the minor's medical record will not be accessible to you (for example, records relating to pregnancy, sexually transmitted diseases, substance use or abuse, and/or fertility awareness services). 

      Right to Receive An Accounting of Disclosures.  Upon request, you may obtain an accounting of certain disclosures of your PHI made by us during any period of time prior to the date of your request provided such period does not exceed six years and does not apply to disclosures that occurred prior to April 14, 2003.  If you request an accounting more than once during a twelve (12) month period, we will charge you a reasonable amount for the accounting statement.  We will respond to your request for an accounting within thirty (30) days of receiving the request.

      Right to Receive Paper Copy of this Notice.  Upon request, you may obtain a paper copy of this Notice, even if you have agreed to receive such notice electronically.  In an emergency situation, we will send you the notice as soon as possible after the emergency (usually, by mail).

EFFECTIVE  DATE and DURATION of THIS NOTICE

      Effective Date.  This Notice is effective on April 14, 2003.

      Right to Change Terms of this Notice.  We may change the terms of this Notice at any time.  If we change this Notice, we may make the new notice terms effective for all Protected Health Information that we maintain, including any information created or received prior to issuing the new notice.  If we change this Notice, we will post the new notice in a clear and prominent location where it is reasonable to expect individuals seeking service from us to be able to read the notice, and on our Internet site at www.esasinc.com. We will not post this notice in our ambulances, as it would be unreasonable to do so, due to space limitations. You also may obtain any new notice by contacting the Privacy Office.

      For Further Information; Complaints.  If you desire further information about your privacy rights, are concerned that we have violated your privacy rights or disagree with a decision that we made about access to your PHI, you may contact our Privacy Office.  You may also file written complaints with the Director, Office of Civil Rights of the U.S. Department of Health and Human Services.  Upon request, the Privacy Office will provide you with the correct address for the Director.

WE WILL NOT RETALIATE AGAINST YOU IF YOU FILE A COMPLAINT WITH US OR THE DIRECTOR.

PRIVACY OFFICE

You may contact the Privacy Officer:

Privacy Office

Eastern Shore Ambulance

P.O. Box 6

Sanford, Va 23426

                        Telephone Number: (757)824-5858   E-mail: office@esasinc.com