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- HIPAA Form -

NOTICE OF PRIVACY PRACTICES REGARDING AMBULANCE SERVICE ACCORDING TO THE 

HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT

The Mt. Morris Fire District is required, by law, to maintain the privacy of protected health information (PHI) and to Provide you with this notice of our legal duties and privacy practices with respect to your PHI. All Mt. Morris Fire District employees, staff, and other office personnel are required to abide by the terms of the notice. We reserve the right to make changes to this notice, and any changes will apply to any PHI that is already in our possession. If and when this notice changes, we will post a copy of the changes notice in our office in a prominent location and provide you with a copy upon request.

Right to Request Restrictions: You have the right to request additional restrictions on certain uses and disclosures of your PHI, but we are not required to agree with your request.

Right To Receive Confidential Communications: You have the right to receive communications regarding PHI in a reasonable alternatives manner or location. You must make your request in writing to our Privacy Officer.

Right to Inspect and Copy: You have the right to inspect and receive a copy of 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 our Privacy Officer in order to inspect and/or copy your health information. If you request a copy of the information, we may charge a $10.00 fee.

Right To Accounting of Disclosures: You have the right to request an “accounting” of certain disclosures that we have made about your PHI be submitting your request in writing to our Privacy Officer.

Right to a Paper Copy of this Notice: You have the right to receive a paper copy of this notice at any time, even if you have previously agreed to receive this notice electronically. To obtain a paper copy of this notice, please contact our Privacy Officer.

If you have any questions or if you wish to file a complaint or exercise any rights listed in this notice, please contact: 

The Privacy Officer

Mt. Morris Fire District

15 E. Center St

Mt Morris, IL 61054

“HIPPA” Health Insurance Portability and Accounting Act

USE AND DISCLOSURE OF PHI WITHOUT CONSENT: The Mt. Morris Fire District is permitted, under Federal Law, to make the following uses or disclosures of your PHI without your authorization.  This notice applies to information and records we have about your health, health status, and health care and services you received from the Mt Morris Fire District.

HOW WE MAY USE AND DISCLOSE PHI ABOUT YOU: Treatment We may use your PHI to provide you with medical treatment. For example, we may disclose your PHI to doctors, nurses, technicians, medical students, or other health care providers or personnel who are involved in taking care of you.  

Payment: We may use and disclose PHI to bill and collect payment for the treatment and services you receive from us. For example, we need to provide your health plan or insurance company with information about a treatment or service we performed for you.  

Health Care Operations: We may use and disclose PHI in the course of performing activities called “health care operations”. For example, we may use your PHI to perform business management and general administrative activities, including managing our activities related to complying with HIPPA Privacy Rule.

Treatment Alternatives: We may tell you about or recommend possible treatment options or alternatives that may be of interest to you.

Required by Law: We may use and disclose PHI as required by federal, state, or local law, as long as any disclosure complies with the law and is limited to requirements of the law.

Public Health Activities: We may use and disclose PHI to public health authorities or other persons authorized to carry certain activities related to public health, such as to report disease, injury, birth, or death, or to report child or elderly abuse or neglect, or to notify, a person who may be exposed to a communicable disease in order to control the spread of the disease.

Abuse, Neglect, or Domestic Violence: We may disclose PHI in certain cases to proper government authorities if we reasonably believe that a patient has been a victim of domestic violence, neglect, or abuse.

Health Oversight Activities: We may disclose PHI to a health oversight agency in connection with adults, investigations, inspections, and other activities it undertakes to monitor the health care system, government, health care programs and compliance with certain laws.

Lawsuits and Other Legal Proceedings: We may use and disclose PHI when required by a court or administrative tribunal.

Law Enforcement: Under certain conditions, we may disclose PHI to law enforcement officials for the purpose of reporting or investigating criminal activities.

Coroners, Medical Examiners, Funeral Directors: Under certain conditions we may disclose PHI to any of the above professionals for the purpose of investigations of your case.

Organ and Tissue Donation: Under certain circumstances, we may use or disclose PHI in order to facilitate an organ, eye or tissue donation, and transplantation

Research: With permission from an Institutional Review Board, we may be permitted to use and disclose your PHI for research purposes. We may also discuss limited portions of your PHI, if we receive written assurances that the receipt will safeguard the information.

To Avert Serious Threat to Health or Safety: We may use or disclose PHI about you in limited circumstances when necessary to prevent a threat to the health and/or safety of a person or the public.

Specialized Government Functions: We are permitted to disclose PHI for certain military and veteran activities, for national security and intelligence activities, for health or safety of people in correctional institutions, and for certain public benefit programs.

Disclosures Required by HIPAA Privacy Rule: We are required to disclose PHI to the Secretary of the United States Department of Health and Human Services when requested by the Secretary to review our compliance.

Workers Compensation: We may disclose PHI as authorized by workers compensation laws or other similar programs that provide benefits for work-related injures.

Individuals Involved In Your Care or Payment: We may disclose PHI to people involved in your care or payment for your care if we have a verbal agreement, or if you have the opportunity to object but do not. If you are not present or unable to consent or object, we may exercise professional judgment in determining if disclosures pf PHI is in your best interests.