ATTACHMENT TO AHA REGULATORY ADVISORY
This document contains a
model notice and consent as required under the final privacy rules issued by
HHS pursuant to the Health Insurance Portability and Accountability Act of 1996
(HIPAA). The law firm of Hogan & Hartson, LLP, prepared it for the AHA.
Hospitals can use these
model documents as a means to evaluate their current practices on use and
disclosure of protected health information and can adapt them, as necessary, to
serve as their own notice and consent forms.
February 13, 2001
Note that the following Model has been modified
for ambulance services from the original hospital policy as written by the
above law firm for hospitals by 911 Billing Service and Consultant, Inc.
Areas that will need individual attention by
your service are in red.
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*
MODEL
HIPAA NOTICE OF PRIVACY PRACTICES
Effective
Date: __________
THIS
NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED
AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW IT CAREFULLY.
WHO WILL FOLLOW
THIS NOTICE.
This notice describes our ambulance’s practices and that of:
Ø Any health care professional authorized to enter information into your ambulance chart.
Ø All departments and units of the ambulance service.
Ø Any member of a volunteer group we allow to help you while you are in the care of the ambulance service.
Ø All employees, staff and other ambulance personnel.
Ø [List any other departments in your system, subsidiaries or others entities that will follow this privacy notice for example a billing service or facilities you transport patients to or from]. All these entities, sites and locations follow the terms of this notice. In addition, these entities, sites and locations may share medical information with each other for treatment, payment or ambulance operations purposes described in this notice.
OUR PLEDGE REGARDING MEDICAL INFORMATION:
We are required by law to:
· make sure that medical information that identifies you is kept private;
· give you this notice of our legal duties and privacy practices with respect to medical information about you; and
· follow the terms of the notice that is currently in effect.
Ø For Treatment. We may use medical information about you to provide you with medical treatment or services. We may disclose medical information about you to doctors, nurses, technicians, medical students, or other hospital personnel who are involved in taking care of you with the ambulance service. For example, a doctor treating you for a broken leg may need to know if you have diabetes because diabetes may slow the healing process. In addition, the doctor may need to tell the dietitian if you have diabetes so that we can arrange for appropriate meals. Different departments of the hospital also may share medical information about you in order to coordinate the different things you need, such as prescriptions, lab work and x-rays. We also may disclose medical information about you to people outside the hospital who may be involved in your medical care after you leave the hospital, such as family members, clergy or others we use to provide services that are part of your care.
Ø
For
Payment. We may use and disclose
medical information about you so that the treatment and services you receive at
the ambulance service may be billed to and payment may be collected from you,
an insurance company or a third party.
For example, we may need to give your health care information about
treatment you received at the ambulance service so your health plan will pay us
or reimburse you for the care and transportation. We may also tell your health plan about a
transport you are going to receive to obtain prior approval or to determine
whether your plan will cover the treatment.
Ø
For
Health Care Operations. We may
use and disclose medical information about you for ambulance operations. These uses and disclosures are necessary to
run the ambulance service and make sure that all of our patients receive
quality care. For example, we may use
medical information to review our treatment and services and to evaluate the
performance of our staff in caring for you.
We may also combine medical information about many ambulance patients to
decide what additional services the ambulance service should offer, what
services are not needed, and whether certain new treatments are effective. We may also disclose information to doctors,
nurses, technicians, medical students, and other ambulance personnel for review
and learning purposes. We may also
combine the medical information we have with medical information from other
ambulance services to compare how we are doing and see where we can make
improvements in the care and services we offer.
We may remove information that identifies you from this set of medical
information so others may use it to study health care and health care delivery
without learning who the specific patients are.
Ø
Appointment
Reminders. We may use and
disclose medical information to contact you as a reminder that you have an
appointment for transportation for medical care with the ambulance service.
Ø
Treatment
Alternatives. We may use and
disclose medical information to tell you about or recommend possible
transportation options or alternatives that may be of interest to you.
Ø
Health-Related
Benefits and Services. We may
use and disclose medical information to tell you about health-related benefits
or services that may be of interest to you.
Ø
Fundraising
Activities. We may use medical
information about you to contact you in an effort to raise money for the
ambulance service and its operations. We
may disclose medical information to a foundation related to the ambulance so
that the foundation may contact you in raising money for the ambulance
service. We only would release contact
information; such as your name, address and phone number and the dates you
received treatment or services at with the ambulance service. If you do not want the ambulance service to
contact you for fundraising efforts, you must notify the
director in writing.
Ø
Individuals
Involved in Your Care or Payment for Your Care. We may release medical information about you
to a friend or family member who is involved in your medical care. We may also give information to someone who
helps pay for your care. In addition, we
may disclose medical information about you to an entity assisting in a disaster
relief effort so that your family can be notified about your condition, status
and location.
Ø
Research. Under certain circumstances, we may use and
disclose medical information about you for research purposes. For Example, a research project may involve
comparing the health and recovery of all patients who received one medication
to those who received another, for the same condition. All research projects,
however, are subject to a special approval process. This process evaluates a proposed research
project and its use of medical information, trying to balance the research
needs with patients' need for privacy of their medical information. Before we use or disclose medical information
for research, the project will have been approved through this research
approval process, but we may, however, disclose medical information about you
to people preparing to conduct a research project, for example, to help them
look for patients with specific medical needs, so long as the medical
information they review does not leave the ambulance service. We will almost always ask for your specific
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 with the
ambulance service.
Ø
As
Required By Law. We will
disclose medical information about you when required to do so by federal, state
or local law.
Ø
To
Avert a Serious Threat to Health or Safety. 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.
SPECIAL SITUATIONS
Ø
Organ
and Tissue Donation. If you are
an organ donor, we may release medical information to organizations that handle
organ procurement or organ, eye or tissue transplantation or to an organ
donation bank, as necessary to facilitate organ or tissue donation and
transplantation.
Ø
Workers'
Compensation. We may release
medical information about you for workers' compensation or similar programs. These programs provide benefits for
work-related injuries or illness.
Ø
Public
Health Risks. We may disclose
medical information about you for public health activities. These activities generally include the
following:
·
to prevent or control disease, injury or
disability;
·
to report births and deaths;
·
to report child abuse or neglect;
·
to report reactions to medications or problems
with products;
·
to notify people of recalls of products they may
be using;
·
to notify a person who may have been exposed to
a disease or may be at risk for contracting or spreading a disease or
condition;
·
to notify the
appropriate government authority if we believe a patient has been the victim of
abuse, neglect or domestic violence. We
will only make this disclosure if you agree or when required or authorized by
law.
Ø
Health
Oversight Activities. We may
disclose medical information to a health oversight agency for activities
authorized by law. These oversight
activities include, for example, audits, investigations, inspections, and
licensure. These activities are
necessary for the government to monitor the health care system, government
programs, and compliance with civil rights laws.
Ø Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, we may disclose medical information about you in response to a court or administrative order. We may also disclose medical information about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.
Ø
Law
Enforcement. We may release
medical information if asked to do so by a law enforcement official:
·
In response to a court order, subpoena, warrant,
summons or similar process;
·
To identify or locate a suspect, fugitive,
material witness, or missing person;
·
About the victim of a crime if, under certain
limited circumstances, we are unable to obtain the person's agreement;
·
About a death we believe may be the result of
criminal conduct;
·
About criminal conduct at the ambulance service;
and
·
In emergency circumstances to report a crime;
the location of the crime or victims; or the identity, description or location
of the person who committed the crime.
Ø
Coroners,
Medical Examiners and Funeral Directors. We may release medical 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 also release medical
information about patients of the ambulance service to funeral directors as
necessary to carry out their duties.
Ø
National
Security and Intelligence Activities.
We may release medical information about you to authorized federal officials
for intelligence, counterintelligence, and other national security activities
authorized by law.
Ø
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.
Ø Inmates. If you are an inmate of a correctional institution or under 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 (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) for the safety and security of the correctional institution.
YOUR RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOU.
You have the following rights regarding medical information we maintain about you:
Ø Right to Inspect and Copy. You have the right to inspect and copy medical information that may be used to make decisions about your care. Usually, this includes medical and billing records, but does not include psychotherapy notes.
To inspect and copy medical information that may be used to make decisions about you, you must submit your request in writing to the director. If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other supplies associated with your request.
We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to medical information, you may request that the denial be reviewed. Another licensed health care professional chosen by the ambulance service will review your request and the denial. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review.
Ø Right to Amend. If you feel that medical 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 for as long as the information is kept by or for the ambulance service.
To request an amendment, your request must be made in writing and submitted to the director. In addition, 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:
· Was not created by us, unless the person or entity that created the information is no longer available to make the amendment;
· Is not part of the medical information kept by or for the ambulance service;
· Is not part of the information which you would be permitted to inspect and copy; or
· Is accurate and complete.
Ø Right to an Accounting of Disclosures. You have the right to request an "accounting of disclosures." This is a list of the disclosures we made of medical information about you.
To request this list or accounting of disclosures, you must submit your request in writing to the director. Your request must state a time period which may not be longer than six years and may not include dates before February 26, 2003 (or the actual implementation date of this act). Your request should indicate in what form you want the list (for example, on paper, electronically). The first list you request within a 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.
Ø Right to Request Restrictions. You have the right to request a restriction or limitation on the medical 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 medical information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend. For example, you could ask that we not use or disclose information about transportation 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 must make your request in writing to the director. In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit our use, disclosure or both; and (3) to whom you want the limits to apply, for example, disclosures to your spouse.
Ø Right 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 must make your request in writing to the director. 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.
Ø Right to a Paper Copy of This Notice. 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 this notice electronically, you are still entitled to a paper copy of this notice.
You may obtain a copy of this notice at our website, www._____.
To obtain a paper copy of this notice, __________.
CHANGES TO THIS NOTICE
Ø We reserve the right to change this notice. We reserve the right 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 copy of the current notice in the hospital. The notice will contain on the first page, in the top right-hand corner, the effective date. In addition, each time you register at or are admitted to the hospital for treatment or health care services as an inpatient or outpatient, we will offer you a copy of the current notice in effect.
COMPLAINTS
If you believe your privacy rights have been violated, you may file a complaint with the ambulance service or with the Secretary of the Department of Health and Human Services. To file a complaint with the ambulance service, contact [insert the name, title, and phone number of the contact person or office responsible for handling complaints. This should be the same person or department listed on the first page as the contact for more information about this notice.]. All complaints must be submitted in writing.
You will not be penalized for filing a complaint.
OTHER USES OF MEDICAL INFORMATION.
Other uses and disclosures of medical information not covered by this notice or the laws that apply to us will be made only with your written permission. If you provide us permission to use or disclose medical information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose medical information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provided to you.
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The final HIPAA privacy rules prohibit the notice and consent from
being combined into a single document.
The consent form is combined with the notice in this model document for
convenience only.
MODEL HIPAA CONSENT
[Name of Ambulance Service]
Patient Consent Form
Our Notice of Privacy Practices provides information about how we may use and disclose protected health information about you. You have the right to review our notice before signing this consent. As provided in our notice, the terms of our notice may change. If we change our notice, you may obtain a revised copy by ______________.
You have the right to request that we restrict how protected health information about you is used or disclosed for treatment, payment or health care operations. We are not required to agree to this restriction, but if we do, we are bound by our agreement.
By signing this form, you consent to our use and disclosure of protected health information about you for treatment, payment and health care operations. You have the right to revoke this consent, in writing, except where we have already made disclosures in reliance on your prior consent.