Privacy Practices

Effective: April 14, 2003/ Revised: April 18, 2013

NOTICE OF PRIVACY PRACTICES FOR
PARKLAND AMBULANCE SERVICE, INC.
d/b/a
MOHAWK AMBULANCE SERVICE

THIS NOTICE DESCRIBES HOW YOUR HEALTH INFORMATION
MAY BE USED AND DISCLOSED AND YOUR RIGHTS WITH RESPECT TO YOUR HEALTH INFORMATION. PLEASE REVIEW IT CAREFULLY.

Mohawk is required by law to maintain the privacy of your health information and to provide you with notice of Mohawks legal duties and privacy practices with respect to your health information. . Under certain circumstances, Mohawk Ambulance Service may be required to notify patients regarding a breach of unsecured protected health information. Mohawk is required to abide by the terms set forth in this notice. We reserve the right to change this notice and to make the changed notice effective for medical information we already have about you as well as any information we receive in the future. We will provide a revised copy of this notice to you upon your request.

I. HOW MOHAWK MAY USE & DISCLOSE YOUR MEDICAL INFORMATION

Mohawk may use your health information for the purposes of providing medical treatment, obtaining payment for services rendered, and/or administering health care operations, as well as for the purposes set forth in this notice or otherwise as authorized or required by law. Mohawk will restrict access to your health information to persons who are directly involved in those functions. All other uses and disclosures of your health information will not be made without your authorization, which you may revoke by providing Mohawk with a written notice. The law also requires your written authorization before we may use or disclose: (a) psychotherapy notes, other than for our treatment, payment or healthcare operations purposes, (b) any PHI for our marketing purposes or (c) any PHI as part of sale of PHI. Some examples of how Mohawk may use and disclose your health information are:

A. Uses and Disclosures For Treatment: For example, a paramedic who is directly involved in your treatment, must and shall be allowed access to your health information as well as be permitted to share it with another paramedic, a medical director or Mohawk personnel who participates in your treatment. We may use and disclose medical 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. Any disclosure, however, would only be to someone able to help prevent the threat.

B. Uses and Disclosures For Payment: For example, we may give your health plan, or other payor, your medical information in order to identify the treatment, bill for services or receive payment. We also may disclose your health information to another covered entity or a health care provider for their payment activities.

C. Uses and Disclosures For Health Care Operations: These types of uses and disclosures of your health information are necessary to run the ambulance company and make sure that all of our Patients receive quality services. For example, we may use medical information about you to review our treatment procedures and to evaluate the performance of our staff. We may also disclose your health information to another health care provider for its health care operations, provided they have or had a direct relationship in your care, and to government regulators.

D. Other Permitted Uses and Disclosures: Mohawk may use or disclose your health information, provided you have an opportunity to agree, prohibit or restrict the use or disclosure, to a family member, other relative, a close personal friend, or anyone identified by you, who is involved in your medical care or payment for your care. If you do not have the opportunity to agree or object to such use or disclosure because you are not present or because of your incapacity or emergency circumstances, Mohawk may, in the exercise of professional judgment and its experience with common practice, determine whether the disclosure is in your best interest and, if so, disclose health information that is directly relevant to that persons involvement with your care.

II. Your Rights with Respect to Your Health Information

A. Your Right to Inspect and Copy: You have the right to inspect and copy your health information that may be used to make decisions about your care. If you are a parent or legal guardian of a Patient, you may also obtain a copy of the health care information of your non-emancipated child(ren), except where prohibited by law for specific health care services.

Requests for copies of your health information must be made in writing to Mohawks Business Office at the address in paragraph H of this Notice. Such requests must be made on Mohawks Medical Authorization release form, which may be obtained from the Business Office. Requests must include the notarized signature of the Patient, or the Patients parent or legal guardian in the event that the Patient is a non-emancipated minor.

We may deny your request to inspect and copy in limited circumstances. If you are denied access to medical information, you may request that the denial be reviewed. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review.

B. Your Right to Request Amendments: If you feel that medical information about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by or for Mohawk. To request an amendment, your request must be made in writing and submitted to the Business Office. You must provide a reason that supports your request.

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: (a) was not created by Mohawk, unless the person or entity that created the information is no longer available to make the amendment; (b) is not part of the medical information kept by or for Mohawk; (c) is not part of the information that you would be permitted to inspect and copy; or (d) is accurate and complete.

C. Your Right to Request Restrictions: You have the right to request a restriction or limitation on the medical information we use or disclose about you. 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 with emergency treatment. We must, however, agree to a restriction on the use or disclosure of your PHI if: (a) the disclosure is for our payment or healthcare operations purposes and (b) if you or another person acting on your behalf has paid for our services in full. To request restrictions, you must make your request in writing to the Business Office. Such requests must include the information you want to limit; whether you want to limit our use, disclosure, or both; and the person(s) to whom you want these limits to apply (e.g., disclosures to your family).

D. Your Right to Request Confidential Communications: You have the right to request that we communicate with you regarding 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 must make your request in writing to the Business Office. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.

E. Your Right to an Accounting of Disclosures: You have the right to request a list of the disclosures we made of your health information for purposes other than treatment, payment or health care operations. To request a list of disclosures, you must submit your request in writing to the Business Office. Your request 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. The first list you request within a twelve (12) month period will be free. For additional lists, 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 incurred.

F. Your 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 agreed to receive this notice in electronic form, you may receive a paper copy upon request. You may also obtain a copy of this notice at our website, www.mohawkambulanceservice.com. To obtain a paper copy of this notice, you must submit your request in writing to Mohawks Business Office.

G. Complaints: If you believe your privacy rights have been violated, you have the right to file a complaint with Mohawk and with the Secretary of Health and Human Services. To file a complaint with Mohawk, send it in writing to: Mohawk Ambulance Service, Administrative Offices, 357 Kings Road, Schenectady, New York 12304, Attn: Designated Privacy Administrator. All complaints must be received in writing. Mohawk does not have a process in place for verbal complaints. You will not be penalized or discriminated against for filing a complaint.

H. Designated Privacy Administrator: Requests for further information should be addressed to Mohawk Ambulance Service, Administrative Offices, 357 Kings Road, Schenectady, New York 12304, Attn: Designated Privacy Administrator.