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Dear Patient: Johnsburg Emergency Squad, Inc. (JES) recently transported you to Glens Falls Hospital or another facility. We hope that this letter finds you recovering well.
Johnsburg Emergency is a non-profit company serving the residents and visitors of the Town of Johnsburg and surrounding areas. We are committed to providing advanced level care to the community, and along with that commitment comes a high cost of readiness. JES relies on the collection of insurance payment for services provided to patients to maintain this readiness and level of care. This includes the collection of co-payments.
Notice of Privacy Practices
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.
The Johnsburg Emergency Squad (ambulance service) 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. This Notice describes your legal rights, advises you of our privacy practices, and lets you know how the ambulance service is permitted to use and disclose PHI about you.
Uses and Disclosures of PHI.
The ambulance service may use PHI for the purposes of treatment, payment, and health care operations, without your permission. Examples of our use of your PHI include: For treatment. This includes verbal and written information that we obtain about you and use for your treatment, or that is used by other medical personnel to whom we transfer your care. For payment. This includes actions we take in order to get reimbursed for the services we provide to you, such as submitting bills to insurance companies. For health care operations. This includes quality assurance and improvement activities, licensing, and training programs.
Additional Uses and Disclosures of PHI Without Your Authorization.
The ambulance service is permitted to use or disclose your PHI without your written authorization in certain situations, including:
-When we are required to do so by law;
-To a family member, other relative, close personal friend, or other person identified by you if we have 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, or if we infer from the circumstances that you would not object. For example, we may assume you agree to our disclosure of your PHI to your spouse when your spouse has called the ambulance for you. In situations where you are not capable of objecting due to your medical emergency or your incapacity, we may use our professional judgment to determine that a disclosure to your family member, relative, or friend is in your best interest. In that situation, we will disclose only that information which is directly relevant to that person’s involvement in your care;
-As part of a public health investigation, or to notify a person about exposure to a communicable disease;
-To a correctional institution if the disclosure is necessary for the health and safety of the inmate or correctional staff;
-For health oversight activities including audits or government investigations, inspections, licensure or
disciplinary actions, or other administrative actions the government takes to oversee the health care system;
-For judicial and administrative proceedings as required by a court or administrative order, or in response to a judicial subpoena;
-For law enforcement activities in limited situations, such as when the information is needed to locate a suspect or stop a crime;
-For military, national defense and security, or other special government functions;
-For workers’ compensation purposes;
-To coroners, medical examiners, and funeral directors for the purpose of identifying a deceased person,
determining cause of death, or carrying out their duties as authorized by law;
-If you are an organ donor, we may release health information as necessary to facilitate organ donation and
Use and Disclosure With Your Authorization.
You may give us written authorization to use your PHI or to disclose it to anyone for any purpose. You may revoke that authorization at any time, in writing, but your revocation will not affect uses or disclosures made while the authorization was in effect.
You have the right to look at or get copies of your PHI. You may come to our offices and look at your medical information or you may ask us to mail the information to you. In either case your request must be in writing, sent to us at the address listed at the end of this Notice.
The right to amend your PHI. You have the right to ask us to amend written PHI we have about you. Generally, we will amend your PHI within 60 days of your request and will notify you when we have amended the information. We may also deny your request to amend your PHI if we believe the information is accurate and complete as written. If you wish to request that we amend your PHI, send your request to the privacy officer listed at the end of this Notice.
The right to an accounting of our disclosure of your PHI
You have the right to receive an accounting of our disclosures of your PHI, other than for treatment, payment, health care operations, or upon your authorization. You may request such an accounting by writing 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 request that we place additional restrictions on our use and disclosure of your medical information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement, except if you need emergency treatment and the restricted PHI is needed to provide the emergency treatment.
Alternative Communication. You have the right to request and we must accommodate reasonable requests to communicate with you about your PHI by alternative means or at alternative locations. For example, you may request that we send all correspondence to you at a post office box rather than to your home address.
Electronic and Paper Copies of This Notice
A copy of this Notice is available on our web site, johnsburgemergencysquad.com You may always request a paper copy of the Notice, or a digital copy can be sent through the email address listed on top of first page.
Revisions to the Notice:
The ambulance service reserves the right to change the terms of this Notice at any time, and the changes will apply to all PHI that we maintain. Any material changes to the Notice will be posted in our facilities and on our web site johnsburgemergencysquad.com. You can also get a copy of the latest version of this Notice by contacting the president and privacy officer listed above.
Your Legal Rights and Complaints: You also have the right to complain to us, or to the Secretary of the 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 the President listed at the top of this Notice.
The following information is included in the signature authorization statement signed by you or an authorized representative at the time of service: I request that payment of authorized Medicare, Medicaid, or other insurance benefits be made on my behalf to the ambulance service for any services provided to me by the ambulance service now or in the future. I understand that I am financially responsible for the services provided to me by the ambulance, regardless of my insurance coverage, and in some cases may be responsible for an amount in addition to that which was paid by my insurance. I agree to immediately remit to the ambulance any payments that I receive directly from insurance or any other source, whatsoever, for the services provided to me and I assign all rights to such payments to the ambulance service. I authorize the ambulance service to appeal payment denials or other adverse decisions on my behalf without further authorization. I authorize and direct any holder of medical information or documentation about me to release such information to the ambulance service and its billing agents, and/or the Centers for Medicare and Medicaid Services and its carriers and agents, and/or any other payers or insurers as may be necessary to determine these or other benefits payable for any services provided to me by the ambulance service, now or in the future. A copy of this form is as valid as an original.
IMPORTANT BILLING INFORMATION
The Johnsburg Emergency Squad is a non-profit company serving the residents and visitors of the Towns of Johnsburg and Minerva and surrounding areas. We are committed to providing advanced level care to the community, and along with that commitment comes a high cost of readiness. We cannot maintain this readiness and level of care without the collection of insurance payment for the services we provide. This includes the collection of co-payments.
Our billing provider, Emergency Management Resources, LLC, may be in contact with you for insurance or payment information. Please take a minute to answer their correspondence. All payments and co-payments should be remitted to the squad to the address below:
Johnsburg Emergency Squad, Inc.
PO Box 787
Latham, New York 12110
Should you receive a payment directly from your insurance carrier for services provided by JES, please endorse the back of the check and forward to the address above. Failure to forward this patient-directed insurance payment is considered theft of services.
Please contact Emergency Management Resources at 888-603-2455 ext 23, if you have any questions regarding your bill, ability to pay, or would like to discuss payment options. Payments may also be made online at www.EMR-LLC.com/PatientInfo
Thank you, and get well!
Please visit us at johnsburgemergencysquad.com
President, Johnsburg Emergency Squad