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Privacy Notice

                                TRI-CITY AMBULANCE SERVICE/GENEVA FIRE DEPARTMENT 
                                                            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 INORMATION 

                                                            ~ PLEASE REVIEW CAREFULLY ~
Purpose of this Notice: The Tri-City Ambulance Service/St. Charles, Geneva and Batavia Fire Departments are required by law to maintain the privacy of certain confidential health care information, known as Protected Health Information, or PHI, and to provide patients with a notice of our legal duties and privacy practices with respect to PHI. This Notice describes a patient’s legal rights, the Tri-City Ambulance Service’s/ St. Charles, Geneva and Batavia Fire Departments privacy practices, and identifies how the Tri-City Ambulance Service/ St. Charles, Geneva and Batavia Fire Departments are permitted to use and disclose PHI. Uses and Disclosures of PHI: The Tri-City Ambulance Service/ St. Charles, Geneva and Batavia Fire Departments may use PHI for the purposes of treatment, payment, and health care operations, in most cases without a patient’s written permission. Examples of The Tri-City Ambulance Service’s/ St. Charles, Geneva and Batavia Fire Departments use of PHI:

For treatment: This includes use of information that we obtain pertaining to a patient’s medical condition and treatment provided by the Tri-City Ambulance Service/ St. Charles, Geneva and Batavia Fire Departments and other medical personnel. It also includes information the Tri-City Ambulance Service/ St. Charles, Geneva and Batavia Fire Departments discloses to other health care personnel to whom the Tri-City Ambulance Service/St. Charles Fire Department transfers patient care and includes disclosure via radio or telephone to the hospital or dispatch center as well as providing the hospital with a copy of the written record created.
For payment: This includes any activities the Tri-City Ambulance Service/ St. Charles, Geneva and Batavia Fire Departments must undertake in order to be reimbursed for the services provided, including such things as submitting bills to insurance companies and other billing agencies.

For health care operations: This includes quality assurance activities, licensing, and training programs, appropriate internal investigations, processing grievances and complaints.

Other Use and Disclosure of PHI Without Authorization: The Tri-City Ambulance Service/ St. Charles, Geneva and Batavia Fire Departments may disclose PHI without a patient’s written authorization or opportunity to object in certain situations as permitted or required by federal, state, or local law.

Any other use or disclosure of PHI, other than those listed above will only be made with a patient’s written authorization. You may revoke your authorization at any time, in writing, except to the extent that we have already used or disclosed medical information in reliance on that authorization.

  • Patient’s Rights: As a patient, you have a number or rights with respect to the protection of your PHI, including:
  • Patients have a right to access, inspect, and copy most of the medical information the Tri-City Ambulance Service St. Charles, Geneva and Batavia Fire Departments maintains about them.
  • Patients have the right to request an amendment to written medical information that the Tri-City Ambulance Service/ St. Charles, Geneva and Batavia Fire Departments may have about them.
  • Patients may request an account of certain disclosures of medical information that the Tri-City Ambulance Service/ St. Charles, Geneva and Batavia Fire Departments has made about them.
  • Patients have the right to request a restriction to the use and disclosure of medical information about them. Tri-City Ambulance Service/ St. Charles, Geneva and Batavia Fire Departments is not required to agree to any restrictions requested, but any restriction agreed to by the Tri-City Ambulance Service/ St. Charles, Geneva and Batavia Fire Departments is binding.

Revisions to the Notice – The Tri-City Ambulance Service/ St. Charles, Geneva and Batavia Fire Departments reserves 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 the Service/Department maintains. To file a comment, complaint, question or request within the Tri-City Ambulance Service/ St. Charles, Geneva and Batavia Fire Departments, contact:

ADMINISTRATOR
Tri-City Ambulance
112 North Riverside Avenue
St. Charles, IL 60174

Telephone: 630-762-7036
Fax: 630-762-7035