Notice of Privacy Practices

West Des Moines EMS

dba: Iowa EMS Alliance


    Iowa EMS Alliance is committed to protecting your personal health information. We are
required by law to maintain the privacy of health information that could reasonably be used to
identify you, known as “protected health information” or “PHI.” We are also required by law to
provide you with the attached detailed Notice of Privacy Practices (“Notice”) explaining our
legal duties and privacy practices with respect to your PHI.

    We respect your privacy, and treat all healthcare information about our patients with care
under strict policies of confidentiality that our staff is committed to following at all times.


Detailed Notice of Privacy Practices

Purpose of This Notice: This Notice describes your legal rights, advises you of our privacy
practices, and lets you know how Iowa EMS Alliance is permitted to use and disclose PHI about

Uses and Disclosures of Your PHI We Can Make Without Your Authorization

    Iowa EMS Alliance may use or disclose your PHI without your authorization, or without
providing you with an opportunity to object, for the following purposes:

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 healthcare personnel to whom
we transfer your care and treatment, and includes transfer of PHI via radio or telephone to the
hospital or dispatch center 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.

Payment. This includes any activities we must undertake in order to get reimbursed for the
services that we provide to you, including such things as organizing your PHI, submitting bills to
insurance companies (either directly or through a third party billing company), managing billed
claims for services rendered, performing medical necessity determinations and reviews,
performing utilization reviews, and collecting outstanding accounts.

Healthcare 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, obtaining legal and financial services, conducting business planning,
processing grievances and complaints, creating reports that do not individually identify you for
data collection purposes, fundraising, and certain marketing activities.

Fundraising. We may contact you when we are in the process of raising funds for Iowa EMS
Alliance, or to provide you with information about our annual subscription program.
In addition, we may use your PHI for certain fundraising activities. For example, we may use
PHI that we collect about you, such as your name, home address, phone number or other
information, in order to contact you to raise funds for our agency. We may also share this
information with another organization that may contact you to raise money on our behalf. If
Iowa EMS Alliance does use your PHI to conduct fundraising activities, you have the right to opt
out of receiving such fundraising communications from Iowa EMS Alliance. If you do not want
to be contacted for our fundraising efforts, you should contact our HIPAA Compliance Officer,
Compliance Name, in writing, by phone, or by email. Contact information for our HIPAA
Compliance Officer is listed at the end of this Notice. We will also remind you of this right to
opt out of receiving future fundraising communications every time that we use your PHI to
conduct fundraising and contact you to raise funds. Iowa EMS Alliance will not condition the
provision of medical care on your willingness, or non-willingness, to receive fundraising

Reminders for Scheduled Transports and Information on Other Services. We may also contact
you to provide you with a reminder of any scheduled appointments for non-emergency
ambulance and medical transportation, or for other information about alternative services we
provide or other health-related benefits and services that may be of interest to you.

Other Uses and Disclosure of Your PHI We Can Make Without Authorization.

    Iowa EMS Alliance is also permitted to use or disclose your PHI without your written
authorization in situations including:

? -For the treatment activities of another healthcare provider;
? -To another healthcare provider or entity for the payment activities of the provider or
entity that receives the information (such as your hospital or insurance company);
?-To another healthcare provider (such as the hospital to which you are transported) for
the healthcare operations activities of the entity that receives the information as long as
the entity receiving the information has or has had a relationship with you and the PHI
pertains to that relationship;
? -For healthcare fraud and abuse detection or for activities related to compliance with the
? -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. We may
also disclose health information to your family, relatives, or friends if we infer from the
circumstances that you would not object. For example, we may assume that you agree
to our disclosure of your personal health information to your spouse when your spouse
has called the ambulance for you. In situations where you are incapable of objecting
(because you are not present or due to your incapacity or medical emergency), we may,
in our professional judgment, determine that a disclosure to your family member,
relative, or friend is in your best interest. In that situation, we will disclose only health
information relevant to that person's involvement in your care. For example, we may
inform the person who accompanied you in the ambulance that you have certain
symptoms and we may give that person an update on your vital signs and treatment
that is being administered by our ambulance crew;
? -To a public health authority in certain situations (such as reporting a birth, death or
disease, as required by law), as part of a public health investigation, to report child or
adult abuse, neglect or domestic violence, to report adverse events such as product
defects, or to notify a person about exposure to a possible communicable disease, as
required by law;
? -For health oversight activities including audits or government investigations,
inspections, disciplinary proceedings, and other administrative or judicial actions
undertaken by the government (or their contractors) by law to oversee the healthcare
? -For judicial and administrative proceedings, as required by a court or administrative
order, or in some cases in response to a subpoena or other legal process;
? -For law enforcement activities in limited situations, such as when there is a warrant for
the request, or when the information is needed to locate a suspect or stop a crime;
? -For military, national defense and security and other special government functions;
? -To avert a serious threat to the health and safety of a person or the public at large;
? -For workers’ compensation purposes, and in compliance with workers’ compensation
? -To coroners, medical examiners, and funeral directors for identifying a deceased person,
determining cause of death, or carrying on their duties as authorized by law;
?-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 organ donation and transplantation; and
? -For research projects, but this will be subject to strict oversight and approvals and
health information will be released only when there is a minimal risk to your privacy and
adequate safeguards are in place in accordance with the law.

Uses and Disclosures of Your PHI That Require Your Written Consent

    Any other use or disclosure of PHI, other than those listed above, will only be made with your
written authorization (the authorization must specifically identify the information we seek to
use or disclose, as well as when and how we seek to use or disclose it). Specifically, we must
obtain your written authorization before using or disclosing your: (a) psychotherapy notes,
other than for the purpose of carrying out our own treatment, payment or health care
operations purposes, (b) PHI for marketing when we receive payment to make a marketing
communication; or (c) PHI when engaging in a sale of your PHI. 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

Your Rights Regarding Your PHI

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

Right to access, copy or inspect your PHI. You have the right to inspect and copy most of the
medical information that we collect and maintain about you. Requests for access to your PHI
should be made in writing to our HIPAA Compliance Officer. 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. If you wish to inspect and copy your
medical information, you should contact our HIPAA Compliance Officer.

    We will normally provide you with access to this information within 30 days of your written
request. If we maintain your medical information in electronic format, then you have a right to
obtain a copy of that information in an electronic format. In addition, if you request that we
transmit a copy of your PHI directly to another person, we will do so provided your request is in
writing, signed by you (or your representative), and you clearly identify the designated person
and where to send the copy of your PHI.

    We may also charge you a reasonable cost-based fee for providing you access to your PHI,
subject to the limits of applicable state law.

Right to request an amendment of your PHI. You have the right to ask us to amend protected
health information that we maintain about you. Requests for amendments to your PHI should
be made in writing and you should contact our HIPAA Compliance Officer if you wish to make a
request for amendment and fill out an amendment request form.

    When required by law to do so, we will 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, such as when we
believe that the information you have asked us to amend is correct.

Right to request an accounting of uses and disclosures of your PHI. You may request an
accounting from us of disclosures of your medical information. If you wish to request an
accounting of disclosures of your PHI that are subject to the accounting requirement, you
should contact our HIPAA Compliance Officer and make a request in writing.

    You have the right to receive an accounting of certain disclosures of your PHI made within six
(6) years immediately preceding your request. But, we are not required to provide you with an
accounting of disclosures of your PHI: (a) for purposes of treatment, payment, or healthcare
operations; (b) for disclosures that you expressly authorized; (c) disclosures made to you, your
family or friends, or (d) for disclosures made for law enforcement or certain other
governmental purposes.

Right to request restrictions on uses and disclosures of your PHI. You have the right to request
that we restrict how we use and disclose your medical information for treatment, payment or
healthcare operations purposes, or to restrict the information that is provided to family, friends
and other individuals involved in your healthcare. However, we are only required to abide by a
requested restriction under limited circumstances, and it is generally our policy that we will not
agree to any restrictions unless required by law to do so. If you wish to request a restriction on
the use or disclosure of your PHI, you should contact our HIPAA Compliance Officer and make a
request in writing.

    Iowa EMS Alliance is required to abide by a requested restriction when you ask that we not
release PHI to your health plan (insurer) about a service for which you (or someone on your
behalf) have paid Iowa EMS Alliance in full. We are also required to abide by any restrictions
that we agree to. Notwithstanding, if you request a restriction that we agree to, and the
information you asked us to restrict is needed to provide you with emergency treatment, then
we may disclose the PHI to a healthcare provider to provide you with emergency treatment.

    A restriction may be terminated if you agree to or request the termination. Most current
restrictions may also be terminated by Iowa EMS Alliance as long we notify you. If so, PHI that
is created or received after the restriction is terminated is no longer subject to the restriction.
But, PHI that was restricted prior to the notice to you voiding the restriction must continue to
be treated as restricted PHI.

Right to notice of a breach of unsecured protected health information. If we discover that
there has been a breach of your unsecured PHI, we will notify you about that breach by first class
mail dispatched to the most recent address that we have on file. If you prefer to be
notified about breaches by electronic mail, please contact our HIPAA Compliance Officer, to
make Iowa EMS Alliance aware of this preference and to provide a valid email address to send
the electronic notice. You may withdraw your agreement to receive notice by email at any time
by contacting our Compliance Officer.

Right to request confidential communications. You have the right to request that we send
your PHI to an alternate location (e.g., somewhere other than your home address) or in a
specific manner (e.g., by email rather than regular mail). However, we will only comply with
reasonable requests when required by law to do so. If you wish to request that we
communicate PHI to a specific location or in a specific format, you should contact our HIPAA
Compliance Officer and make a request in writing.

Internet, Email and the Right to Obtain Copy of Paper Notice

    If we maintain a web site, we will prominently post a copy of this Notice on our web site and
make the Notice available electronically through the 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 paper copy
of the Notice.

Revisions to the Notice

Iowa EMS Alliance is required to abide by the terms of the version of this Notice currently in
effect. However, Iowa EMS Alliance 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 PHI that we maintain.
Any material changes to the Notice will be promptly posted in our facilities and on our web site,
if we maintain one. You can get a copy of the latest version of this Notice by contacting our
HIPAA Compliance Officer.

Your Legal Rights and Complaints

    You also have the right to complain to us, 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.

    Should you have any questions, comments or complaints, you may direct all inquiries to our
HIPAA Compliance Officer. Individuals will not be retaliated against for filing a complaint.

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

Compliance Officer
Iowa EMS Alliance
PO Box 65320
8055 Mills Civic Parkway
West Des Moines, Iowa 50265
Phone: 515-273-0652

Effective Date of the Notice: 09/23/13