IMPORTANT: THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. YOUR RIGHTS REGARDING YOUR MEDICAL INFORMATION:
You have the following rights regarding your health information:The Right to Inspect and Copy your PHI: You may review and copy your medical records and information. You should make such a request to us at 123 E. 7th Street, Chattanooga, TN 37402. We have the right to charge a reasonable fee for all copying and mailing expenses.
The Right to Amend your PHI: You may ask that we amend your PHI if you believe that your information is incomplete or incorrect. A request for an amendment should be made in writing and should be sent to us at the above address. Your request must be accompanied by a statement from you regarding why you feel the amendment is proper. We may deny your request if it is not written or if you fail to state a reason for the proposed amendment. We may also deny your request if you ask us to and information that is not part of the information we keep, was not created by us (unless the entity responsible is no longer available), is not part of the information available for you to inspect and copy or is accurate and complete.
The Right to Know about Disclosures of your PHI: You have the right to request an accounting of who we have disclosed your health information to. The request should be made in writing and sent to us at the above address. You must state a time period for your request, which cannot be longer than 6 years. Your first request every 12 months is free. After that we may charge you for additional requests made within 12 months of your last request. Please contact us for the exact cost.
The Right to Request Restrictions of your PHI: You may request a restriction or limitation on how and what health information we disclose regarding you for treatment, payment, health operations or to your family or caregivers. We do not have to agree to your request. Requests for restrictions must be made in writing and sent to us at the address on the other side. Your request must include a statement of what information you want to limit, whether you want to limit its use, disclosure, or both, and to whom you want the limits to apply.
The Right to Confidential Communications: You may request that we communicate with you about medical matters in a certain format or at a specific location. You must request such a confidential communication or specific type or place of communication in writing submitted to us at the address on the reverse side. No reason for this request is necessary and we will honor all reasonable requests.
PLEASE NOTE that we retain the right to alter, amend or change this Notice at any time. Any such revision may be effective on any information we obtain about you in the future or any information that we already have regarding you. A copy of our most current Notice will be on display in our offices.
COMPLAINTS regarding the use of your PHI should be made to us at the address above and/or with the Department of Health and Human Services. All complaints must be submitted in writing. There is no cost or penalty to you for filing a complaint.
You also have the right to request that we restrict the method in which we use or disclose your PHI for purposes of treatment, payment or health care operations. We have the right to refuse to comply with your request.
We will keep and record information about your medical condition. We may use this information or disclose this information to others as follows:
We may use or disclose your PHI in order to treat you. For example, we may advise the health care provider which we are transporting you to of your medical condition, including your vital signs and medications we have administered to you. We may also disclose your condition to family or caregivers who are involved in your medical care.
We may use or disclose your PHI in order to receive payment for the services we provide to you. For example, we may disclose your condition in order for your insurance company to understand why you received treatment so that they will pay your claim. We may also disclose your information to our billing department/attorney/collection agencies in order to seek payment for the services we provide to you.We may use to disclose your PHI for our operations. For example, we may review your information in order to evaluate your treatment and our services in order to insure that our care for you now and in the future is the best that it can be.
We may use your PHI to contact you in the future. We may also disclose your information as required by law.If you have questions about this brochure, your rights, or the care you have received, please contact one of the following phone numbers with your requests:
Billing Office (423) 209-6363
E.M.S. Administrative Office (423) 209-6900
E.M.S. Customer Service (423) 209-6900