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Government Center
7593 Bunnell Hill Road
Springboro, OH 45066
Warren County
CLEARCREEK FIRE DISTRICT

PATIENT PRIVACY NOTICE

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

PLEASE REVIEW CAREFULLY.
 
Clearcreek Fire District (CCFD) is required by law to maintain the privacy of Protected Health Information (PHI) and to provide you with notice of those legal duties and privacy practices with respect to your PHI. This notice describes your legal rights, advises you of our privacy practices, and lets you know how CCFD is permitted to use and disclose your PHI. CCFD is required by law to abide by the terms of the version of this Notice currently in effect. CCFD reserves the right to change the terms of this Notice in the future and to make the new Notice provisions effective for all PHI that it maintains. • The full text of the Notice currently in effect shall be available upon request at the time of service or by contacting the CCFD Privacy Officer as listed at the end of this Notice. The entire Notice currently in effect is also electronically available at the CCFD website, http://www.clearcreektownship.com
 
USES AND DISCLOSURE OF PHI
 
CCFD may use PHI for the purposes of treatment, payment and other health care operations without your consent. Examples of our use of your PHI:
  • For treatment. This includes such things as verbal and written information that we obtain about you and use 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 PHI via radio or telephone to the hospital as well as providing the hospital with a copy of the written report we create in the course of providing you treatment and transport.
  • 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 organizing your PHI and submitting bills to insurance companies (either directly or through a third party billing company), management of billed claims for services rendered, medical necessity determinations and reviews, utilization review, and collection of 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, obtaining legal and financial services, conducting business planning, processing grievances and complaints, creating reports that do not individually identify you for data collection purposes, and certain marketing activities.
CCFD is authorized to use PHI without your consent, authorization, or written permission in certain situations, including:
  • To a public health authority in certain situations (such as reporting a birth, death or disease as required by law, as part of a public health investigation, to report child or adult abuse or neglect or domestic violence, to report adverse events such as product defects, or to notify a person about exposure to a possible communicable disease as required by law);
  • For health oversight activities including audits or government investigations, inspections, disciplinary proceedings, and other administrative or judicial actions undertaken by the government 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 or other legal process;
  • For law enforcement activities in limited situations, such as when there is a warrant for the request, or when the information is needed to locate a suspect or stop a crime;
  • For military, national defense and security and other special government functions;
  • For workers’ compensation purposes, in compliance with workers’ compensation laws;
  • To avert a serious threat to the health and safety to a person or the public at large.
  • For research purposes when information that could be used to identify you has been removed.
 
In addition, PHI may be released in the following situations provided that you have had the opportunity to object if you are present. If you are not present or are incapacitated, CCFD will exercise professional judgment to determine if such release is in your best interest and will release only the minimum necessary information to accomplish the purpose.
 
  • Emergency situations;
  • To a relative, friend or individual involved in your care;
  • For disaster relief operations for coordinating notification of family members, personal representatives, or others.
 
Any other use or disclosure of PHI, other than those listed above will only be made with your written consent or an authorization (an authorization specifically identifies the information we seek to use or disclose, as well as when and how we seek to use or disclose it).

You may revoke your consent or authorizations at any time, in writing, except to the extent that we have already used or disclosed medical information in reliance on that consent or authorization.

YOU HAVE RIGHTS WITH RESPECT TO MEDICAL INFORMATION ABOUT YOU.
 
 Right to a copy of this Notice.
  • You have the right to a paper copy of our Patient Privacy Notice at any time. If you would like a copy, ask a staff member or contact our Privacy Officer listed at the end of this Notice.
Right of access to inspect and copy.
  • You have the right to see or review and receive a copy of medical information about you that we maintain in certain groups of records. We will normally provide you with access to this information within 30 days of your request. We may charge you a reasonable fee to cover the costs of copying. Medical records will be available for 6 years previous from date of request. If you wish to inspect and copy your medical information, contact the Privacy Officer listed at the end of the Notice.

In limited circumstances we may deny you access to your medical information, and certain types of denials may be appealed. We have available forms to request PHI and will provide a written response if we deny you access and let you know your appeal rights.
 
Right to have medical information amended.
  • You have the right to ask us to amend written medical information that we may have about you. 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 only in certain circumstances, like when we believe the information you have asked us to amend is correct. You can appeal our denial of your request to amend the information. If you wish to amend the medical information, contact the Privacy Officer listed at the end of the Notice.
Right to an accounting of our disclosures of your PHI.
  • You may request an accounting from us of certain disclosures of your PHI that we have made in the last six (6) years prior to the date of your request. We are not required to give you an accounting of information we have used or disclosed for purposes of treatment, payment or health care operations, uses or disclosures prior to April 14, 2003, disclosures to you, or incidental disclosures. If you wish to request an accounting of your PHI that we have used or disclosed, you should contact the Privacy Officer listed at the end of the Notice.
 Right to request restrictions on uses and disclosures.
  • You have the right to restrict how we use and disclose your PHI for treatment, payment or health care operations or to restrict the information that is provided to family, friends and other individuals involved in your health care. But if you request a restriction and the information you asked us to restrict is needed to provide you with emergency treatment, then we may use the PHI or disclose the PHI to a health care provider to provide you with emergency treatment. CCFD is NOT required to agree to any restrictions you request, but any restrictions agreed to by CCFD are binding on CCFD.
Right to request a reasonable, alternative method of contact.
  • You have the right to request to be contacted at a different location or by a different method. For example, you may prefer to have all written information mailed to your work address rather than to your home address. If you would like to request an alternative method of contact, you must provide us with that information at the time of service or mail your request to the Privacy Officer listed at the end of the Notice. CCFD will accommodate all reasonable requests.
YOU MAY FILE A COMPLAINT ABOUT OUR PRIVACY PRACTICES
 
You may complain to CCFD or to the Secretary of the US Department of Health and Human Services if you believe your privacy rights have been violated. Such complaints shall be in writing and must be filed within 180 days of when you knew or should have known that the act or omission occurred. CCFD has 30 days from receipt of the complaint to investigate the grievance and notify you in writing of the results of that investigation. We will NOT take any action against you or change our treatment of you in any way if you file a complaint with us or with the federal government.

To file a written complaint with us, mail it to the Privacy Officer for Clearcreek Fire District listed at the end of this Notice.

To file a complaint with the federal government contact the Secretary of the U.S. Department of Health and Human Services at Hubert Humphrey Bldg., 200 Independence Ave SW, Washington, DC 20201, phone number 1-866-627-7748.
 
CONTACT INFORMATION
If you have any questions, or if you wish to exercise any rights listed in this Notice, contact
Privacy Officer, Clearcreek Fire District
925 South Main Street
Springboro, Ohio 45066
 
Effective Date: April 14, 2003