NOTICE OF PRIVACY PRACTICES
PROTECTING YOUR PRIVACY:
It is your right as a patient to be informed of the privacy practices of the North Shore Fire Department that transported you, as well as to be informed of your privacy rights with respect of personal health information (PHI), as stated in the HIPAA act of 1996. The North Shore Fire Department and its billing service, EMS MEDICAL BILLING ASSOCIATES LLC will respond to requests, concerns, or questions regarding this policy or use of your PHI as it relates to obtaining insurance payment, or other health care operation.
NORTH SHORE FIRE DEPARTMENT RESPONSIBILITY:
- Maintain the privacy of your health information.
- Provide you with a notice of legal duties and privacy practices regarding PHI collected and maintained about you.
- Permitted by federal privacy rule to use or disclose your PHI for treatment, payment, or health operations.
- Your PHI may be used for evaluation of patient care services, evaluation of the performance of EMT staff, business projects, and internal audits.
YOUR PHI RIGHTS:
You may request restrictions on uses and disclosures of PHI, even if the restriction effects your treatment or payments to the provider or health operations activities. The fire department is not required to agree to your requested restriction. The North Shore Fire Department or its billing service (EMS MEDICAL BILLING ASSOC.) will accommodate any reasonable request. This request for access to your health care record should be in writing to the compliance officer. The request must be signed by yourself, your power of attorney or personal representative and notarized. Requesting an amendment to your health record, if you believe it is incorrect or incomplete as documented by the fire department, must be in written form and given to the compliance officer. If the North Shore Fire Department does not agree with your request for change, your request may be denied.
PHI USES OR DISCLOSURES WITH OUT YOUR AUTHORIZATION:
Without your written authorization, the North Shore Fire Department may disclose your PHI as required by law. This includes PHI pertaining to workers compensation claim, victims of abuse, neglect or domestic violence for judicial proceedings, for law enforcement purposes, for statutory reporting to the State of WI, for public health safety, a request by state or federal agencies for activities relating to death, tissue donation or serious risk to health and safety.
REQUESTS REGARDING PHI:
All requests regarding your PHI should initiate with EMS Medical Billing Associates. The phone number is 414-365-9900.
Pete Busalacchi, Battalion Chief of EMS is the privacy officer for the North Shore Fire Department and is responsible for the overall administration of your PHI. He can be contacted at (414) 357-0113.