BASALT & RURAL FIRE PROTECTION DISTRICT

Notice of Privacy Practices

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

PLEASE REVIEW THIS NOTICE CAREFULLY AND PRINT A COPY FOR YOUR RECORDS.

 Purpose of this Notice:

Basalt & Rural Fire Protection District is required by law to maintain the privacy of certain confidential health care information, known as protected health information (PHI), and to provide you with a notice of our 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 Basalt & Rural Fire Protection District is permitted to use and disclose PHI about you. Basalt & Rural Fire Protection District is required to abide by the terms of the version of this Notice currently in effect. Current Colorado State and/or Federal statutes are referenced as a resource to you.

Basalt & Rural Fire Protection District’s responsibilities as a provider of emergency medical services:

 We may use your PHI for the purpose of treatment, payment, and other health care operations, as stated below:

• 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 record we create in the course of providing you with 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 (through our third-party billing company), management of billed claims for services rendered, medical necessity determinations and reviews, utilization review, and collection of outstanding accounts.

• For healthcare operations. This includes quality assurance activities, licensing, and training programs to ensure that our personnel meet the highest standards of care and follow established policies and procedures, obtaining legal and financial services, conducting business planning, processing grievances and complaints, and creating reports that do not individually identify you (for data collection purposes). Please note that in using your PHI for these purposes, all identifying factors of you PHI will be removed.

In addition, Basalt & Rural Fire Protection District may be required to release protected health information about you without your permission under the following circumstances:

• To avert a serious threat to health or safety: We may use and disclose health information about you when required to do so by federal, state, or local law.
• Research: We may use and disclose health information about you for research projects that are subject to a special approval process.
• Organ and tissue donation : If you are an organ donor, we may release health information to organizations that handle organ procurement or organ, eye or tissue transplantation or to an organ donation bank, as necessary to facilitate such donation and transplantation.
• Military, Veterans, National Security and Intelligence : If you are or were a member of the armed forces, or part of the national security or intelligence communities, we may be required by military command or other government authorities to release information about you. We may also release information about foreign military personnel to the appropriate foreign military authority.
• Workers’ Compensation : We may release health information about you for workers’ compensation or similar programs. These programs provide benefits for work-related injuries or illness.
• Public Health Risks : We may disclose health information about you for public health reasons in order to prevent or control disease, injury, or disability; or report births, deaths, suspected abuse or neglect, non-accidental physical injuries, reactions to medications or problems with products.
• Health Oversight Activities : We may disclose health information to a health oversight agency for audits, investigations, inspections, or licensing purposes. These disclosures may be necessary for certain state and federal agencies to monitor the health care system, government programs, and compliance with civil rights laws.
• Lawsuits and Disputes: If you are involved in a lawsuit or a dispute, we may disclose health information about you in response to a court or administrative order. Subject to all applicable legal requirements, we may also disclose health information about you in response to a subpoena.
• Law Enforcement: We may release health information if asked to do so by a law enforcement official in response to a court order, subpoena, warrant, summons or similar process, subject to all applicable legal requirements.
• Coroners, Medical Examiners, and Funeral Directors: We may release health information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death.
• Information not personally identifiable: We may use or disclose health information about you in a way that does not personally identify you or reveal who you are.
• Family and friends: We may disclose health information about you to your family members or friends if we obtain your verbal agreement to do so or if we give you an opportunity to object to such a disclosure and you do not raise an objection. In situations where you are not capable of giving consent (because you are not present or due to your incapacity or medical emergency), we may, using our professional judgment, determine that a disclosure to your family member or friends is in your best interest.

Any other use or disclosure of PHI, other than those listed above will only be made with a signed and notarized request from you. You may revoke your request at any time, in writing, except to the extent that we have already used or disclosed medical information in reliance on that consent.

Your rights as a patient:

As a patient, you have a number of rights with respect to the protection of your PHI, including:

The right to access, copy, or inspect your PHI. This means that you may come to our offices and inspect and request a copy of the medical information about you hat we maintain. We have available forms to request PHI, and we will normally provide you with access to this information within 14 days of our receipt of your request. As the patient, you will not be assessed a fee to obtain a copy of any medical information that you have the right to access

If you wish to request a copy of your medical information, you should contact the privacy officer listed at the end of this Notice.

In limited circumstances, we may deny you access to your medical information, and certain types of denials may be appealed. We will provide written response if we deny you access and notify you of your appeal rights.

The right to amend your PHI. 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 to amend your medical information in certain circumstances, for example, when we believe the information you have asked us to amend is incorrect. You can appeal our denial of your request to amend the information.

If you wish to request an accounting of your PHI that we have used or disclosed, you may send a written request to the privacy officer listed at the end of this Notice.

The right to request an accounting of our use and disclosures of your PHI. You may request an accounting from us to certain disclosures of your medical information that we have made in the last six 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 healthcare operations, or of uses or disclosures made prior to April 14, 2003.

If you wish to request an accounting of your PHI that we have used or disclosed, you may send a written request to the privacy officer listed at the end of this Notice.

The right to request that we restrict the uses and disclosures of your PHI. You have the right to restrict how we use and disclose the treatment, payment or healthcare operations, or to restrict the information that is provided to family, friends and other individuals involved in your healthcare. 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 healthcare provider to provide you with emergency treatment. The Basalt & Rural Fire Protection District is not required to agree to any restrictions you request, but any restrictions agreed to by Basalt & Rural Fire Protection District are binding on the Basalt & Rural Fire Protection District.

Legal rights and complaints. Notice of any changes in Basalt & Rural Fire Protection District’s Privacy Policy will be posted on our website, if we maintain one. You can get a copy of the latest version of this Notice by contacting the Privacy Officer identified below. We reserve the right to change the terms of this Notice at any time, and the changes will be effective immediately and will apply to all protected health information that we maintain.

You have the right to complain to Basalt & Rural Fire Protection District, or to the Secretary of the United States Department of Health and Human Services if you believe that your privacy rights have been violated. You will not be retaliated against in any way for filing a complaint with us or to the government.

If you have any questions or if you wish to file a complaint or exercise any rights listed in this Notice, please contact our designated Privacy Officer listed below:

Jerry Peetz, Operations Director
Basalt & Rural Fire Protection District
1089 JW Drive
Carbondale , CO 81623
(970) 704-0675, Fax (970) 704-0625
Email – jpeetz@basaltfire.org

Effective Date of the Notice: 4/14/2003