HIPAA - Privacy Practices
Junction City 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
INFORMATION. PLEASE REVIEW IT CAREFULLY.
If you have questions about this notice or want more information, please contact: Terry L. Johnson,
Privacy Officer at 785-238-6822. The effective date of this notice is November 14, 2016.
To appropriately treat you and receive payment for the services we provide, we need to
obtain information from you including your full name and address, insurance company, family
medical history, current medical history, and current medical condition. We will use and disclose
this information and other information we collect in the ways described below. To help you
understand how we will use and disclose your information we have put the different uses and
disclosures into categories and give examples of each. All of the ways we use or disclose your
information will fit into one of the categories listed below, but we cannot list all of the uses and
discloses in each category.
We may use and disclose your health information for treatment, payment, and health care
Treatment. We may use and disclose your information to provide you with medical
treatment and services. Your information may be disclosed to individuals providing care
to you. These individuals need your information to provide care, and to coordinate and
provide services (such as transfer of your care to the receiving hospital).
Payment. We may use and disclose your information to receive payment for the services
and treatment provided to you. We use your information to create a bill and disclose your
information when we send the bill to your insurance company, you, or a third party. The
individual or entity paying the bill may request more information to determine whether the
bill is covered by your insurance.
- Health Care Operations. We may use and disclose your information for health care
operation purposes. Health care operations includes review of the care you receive for
quality assessment, educational, business planning, and compliance plan purposes.
We may also disclose your health information to outside entities without your consent or
authorization in the following circumstances:
Required by Law. We disclose information as required by law. For example, we are
required to report gunshot wounds to the police.
Public Health Purposes. We disclose information to health agencies as required by law
for preventing or controlling disease. Examples are reporting of sexually transmitted,
communicable, and infectious diseases.
To Prevent a Serious Threat to Health or Safety. We may disclose information about
you to law enforcement or an identified victim to prevent a serious threat to your health or
safety or the health or safety of another individual or the public.
Research. Your information may be used by or disclosed to researchers for research
approved by a privacy board or an institutional review board.
Health Oversight Activities. Your health information may be disclosed to governmental
agencies and boards for investigations, audits, licensing, and compliance purposes.
Judicial and Administrative Proceedings. We may be required to disclose your health
information to a court or for an administrative proceeding.
Law Enforcement Activities. We may be required to disclose your information as
required by law, pursuant to a court order, warrant, subpoena, or summons.
In Emergency Circumstances. We may be required to disclose your information during
a medical emergency related to the commission of a crime, location of a crime or the
victim(s) of a crime, or the identity, description or location of a perpetrator of a crime.
Deceased Individual. We may disclose information for the identification of the body or
to determine the cause of death.
Military and Veterans. If you are a member of the armed forces we may release
information about you as required by military command authorities. We may also release
information about foreign military personnel to the appropriate foreign military authority.
Inmates. If you are an inmate of a correctional institution or under the custody of a law
enforcement official. This release must be necessary (1) for the institution to provide you
with health care; (2) to protect your health and safety or the health and safety of others; or
(3) for the safety or security of the correctional institution.
Organ and Tissue Donation. If you are an organ donor, we may release your medical
information to organizations that handle organ procurement or organ, eye or tissue
transplantation or to an organ bank, as necessary to facilitate organ or tissue donation.
Workers’ Compensation. We may release medical information about you for workers’
compensation or similar programs.
Specialized Governmental Functions. We may release information about you to
authorized Federal officials for intelligence, counterintelligence, and other national
security activities authorized by law.
We will give you the opportunity to object to the following uses and disclosure of your
Notification. We may tell your friends, relatives and other caretakers information which
is relevant to their involvement in your care.
Disaster Relief. We may disclose information about you to public or private agencies for
disaster relief purposes.
Except as provided above, we will obtain your written authorization prior to disclosure of your
information for any other purpose. Specifically, written authorization is required prior to the
disclosure of your information:
Psychotherapy Notes. We will not use or disclose your psychotherapy notes without a
written authorization except as specifically permitted by law.
Marketing. We will not use or disclose your information for marketing purposes, other
than face-to-face communications with you or promotional gifts of nominal value, without
your written authorization.
Sale of Information. We will not sell your Protected Health Information without your
written authorization, including notification of the payment we will receive.
Where a disclosure is made under your written authorization, you have the right to revoke the
authorization at any time. Revocation of an authorization must be in writing. The revocation is
effective as of the date you provide it to us and does not affect any prior disclosures made under
If a state or federal law provides additional restrictions or protections to your information, we will
comply with the most stringent requirement.
You have the right to request a restriction on how information about you is used and
disclosed. If you want to request a restriction of a use or disclosure of your information,
contact our Privacy Officer at the number listed at the beginning of this form. We are
required to agree to a request for a restriction related to disclosure of information to your
health plan for payment or healthcare operations where you pay for the service in full. We
are not otherwise required to agree to any restriction on the use or disclosure of your
You have the right to request communications with you be made at an alternative address
or phone number. To request that communication be made at a different address or phone
number contact our Privacy Officer at the number listed at the beginning of this form to
obtain the form to make your request.
You have the right to inspect and copy your medical record. To inspect and copy your
medical record a request must be made in writing on the form provided by Practice. To
obtain a form contact our Privacy Officer at the number listed at the beginning of this form.
If you believe the information we have about you is incorrect or incomplete you may
request that we amend your medical record. Your request must be made in writing on the
form provided by Practice. To request a form contact our Privacy Officer at the number
listed at the beginning of this form.
You have the right to receive an accounting of disclosures, a list of individuals and entities
that received your health information for reasons other than treatment, payment, or
healthcare operations. You may receive one (1) free accounting during a twelve (12) month
period. If you request more than one (1) accounting in a twelve (12) month period, you
will be charged a fee. An accounting is not provided for disclosures prior to April 14,
You have the right to request a paper copy of this Notice.
We are required by law to maintain the privacy of Protected Health Information and to
provide individuals with this Notice of our legal duties and privacy practice regarding
We are required to notify you if there is a breach of your unsecured Protected Health
We are required to follow the terms of the current Notice.
We may change the terms of this Notice and the revised Notice will apply to all health
information in our possession. If we revise this Notice, a copy of the revised Notice will
be posted and a copy may be requested from our Privacy Officer at the number listed at the
beginning of this form.
If you believe your privacy rights have been violated you may contact:
Terry L. Johnson, Privacy Officer at 785-238-6822 or the Office of Civil Rights. You will not be
penalized for filing a complaint.
NOTICE OF PRIVACY PRACTICES (PDF)
HIPAA\FORMS\NOTICE OF PRIVACY PRACTICES
Effective Date: November 14, 2016