PRIVACY NOTICE

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

The Kent Fire Department is required by law to maintain the privacy of certain confidential health care information, known as Protected Health Information or PHI, and to provide you with a notice of our legal duties and privacy practices with respect to your PHI.� Kent Fire Department is also required to abide by the terms of the version of this notice currently in effect.�� Kent Fire Department takes its responsibility to protect your privacy very seriously and will use your PHI if required in providing necessary medical treatment.� The privacy of your PHI will not be treated lightly.� If you feel the need for more specific information, the following describe the permitted uses.

Uses and Disclosures of PHI: Kent Fire Department may use PHI for the purposes of treatment, payment, and health care operations, in most cases without your written permission. Examples of our use of your PHI:

For Treatment. This includes such things as obtaining verbal and written information about your medical condition and treatment from you as well as from others, such as doctors and nurses who give orders to allow us to provide treatment to you. We may give your PHI to other health care providers involved in your treatment, and may transfer your PHI via radio or telephone to the hospital or dispatch center.

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 submitting bills to insurance companies, making medical necessity determinations and collecting outstanding accounts.

For health care operations. This includes quality assurance activities, licensing, and training programs to ensure that our personnel meet our standards of care and follow established policies and procedures, as well as certain other management functions.

Use and Disclosure of PHI Without Your Authorization. Kent Fire Department is permitted to use PHI without your written authorization, or opportunity to object, in certain situations, and unless prohibited by a more stringent state law, including:

• For the treatment, payment or health care operations activities of another health care provider who treats you;

• For health care and legal compliance activities;

����� To a family member, other relative, or close personal friend or other individual involved in your care 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, and in certain other circumstances where we are unable to obtain your agreement and believe the disclosure is in your best interests for purposes of providing your medical care;

Any other use or disclosure of PHI, other than those listed above will only be made with your 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 Rights: As a patient, you have a number of rights with respect to your PHI, including:

The right to access copy or inspect your PHI.

This means you may inspect and copy most of the medical information about you that we maintain. We will normally provide you with access to this information within 30 days of your request. We may also charge you a reasonable fee for you to copy any medical information that you have a right to access. In limited circumstances, we may deny you access to your medical information, and you may appeal certain types of denials. We have available forms to request access to your PHI and we will provide a written response if we deny you access and let you know your appeal rights. You also have the right to receive confidential communications of your PHI. If you wish to inspect and copy your medical information, you should contact our privacy officer.

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 only in certain circumstances, like when we believe the information is you have asked us to amend is correct. If you wish to request that we amend the medical information that we have about you, you should contact our privacy officer.

The right to request an accounting. You may request an accounting from us of certain disclosures or your medical information that we have made in the 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 the purposes of treatment, payment, or health care operations, or when we share your health information with our business associates, like our billing company or a medical facility to which we have transported you. We are also not required to give you an accounting or our uses of protected health information for which you have already given us written authorization.� If you request an accounting, contact our privacy officer.

The right to request that we restrict the uses and disclosures of your PHI.� You have the right to request that we restrict how we use and disclose your medical information that we have about you. Kent Fire Department is not required to agree to any restrictions you request, but any restrictions agreed to by Kent Fire Department in writing are binding on Kent Fire Department.

Internet, Electronic Mail, and the Right to Obtain Copy of Paper Notice on Request. If we maintain a web site, we will prominently post a copy of this notice on our web site.

�If you allow us, we will forward you this Notice by electronic mail instead of on paper and you may always request a copy of the Notice.

�Revisions to the Notice: Kent Fire Department 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 we maintain. Any material changes to the Notice will be promptly posted in our facilities and posted to our web site, if we maintain one.� You will be provided a copy of the latest version of this Notice by contacting our privacy officer.

�Your Legal Rights and Complaints: You also have the right to complain to us, or the Secretary of the United States Department of Health and Human Services if you believe 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. Should you have any questions, comments or complaints you may direct all inquiries to our privacy officer.

�Privacy Officer Contact Information:

Chief James A. Williams

Privacy Officer

Kent Fire Department

320 S. Depeyster St.

Kent, Ohio 44240

330-676-7393 Office

330-676-7374 Fax

�

Effective Date of Notice: April 14, 2003