5189 Commerce Rd.

Flint, Michigan 48507

Notice of Privacy Practices Regarding Protected

Health Information
Patriot Ambulance Service, Inc.
NOTICE OF PRIVACY PRACTICES
REGARDING PROTECTED HEALTH INFORMATION
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.

Patriot Ambulance Service, Inc., through its subsidiaries and affiliates, provides medical transportation and related
services. These subsidiaries and affiliates providing such services are hereinafter referred to as "The Company," "we," "our,"
or "us." Due to the nature of these services, we are required by law to maintain the privacy of certain confidential health care
information, known as Protected Health Information (PHI), and to provide you with a notice of our legal duties and privacy
practices with respect to your PHI. We are also required to abide by the terms of the version of this Notice currently in effect.

Uses and Disclosures of PHI:

We may use PHI for the purposes of treatment, payment and health care operations, in most cases without your written permission.

Examples of our uses of PHI:

Treatment: This includes such things as obtaining verbal and written information about your
medical condition and treatment from you as well as 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.
Payment: This includes any activities we must undertake in order to get reimbursed for the
services we provided you, including such things as submitting bills to insurance companies,
making medical necessity determinations, utilization reviews or hearings, and collection
activities.
Health Care Operations: This includes quality assurance activities, licensing, and training
programs to ensure that our personnel follow actable health care guidelines, conducting business
planning, processing complaints, and obtaining legal and/or financial services.
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 transportation.
Business Associates: We may share your PHI with business associates that perform certain
TPO activities on our behalf such as billing, dispatch, and quality assurance reviews. We will have

a written agreement with our business associates that require them to protect the privacy of
your PHI.

USES AND DISCLOSURES OF PHI AFTER YOU HAVE AN OPPORTUNITY TO AGREE OR

OBJECT:
We may disclose to a member of your family, a relative, a close friend or any other person
that you identify, your PHI that is directly relevant to that persons involvement in your health
care. We may use or disclose your PHI for notifying your family member, personal representative,
or any other person that is responsible for your care, of your location, general condition, or
death. We may also disclose your PHI to an authorized public or private entity to assist in
disaster relief efforts. You will be given an opportunity to agree or object before the company
used or discloses your PHI for these purposes. If you object to the disclosure, we will not disclose
the PHI to the person. However, in emergency circumstances or if you are incapacitated, our staff
will then release only PHI directly relevant to that persons involvement in your healthcare.

USES AND DISCLOSURES OF PHI WITHOUT YOUR AUTORIZATION OR OPPORTUNITY TO

OBJECT:
Patriot Ambulance is permitted or required to use your PHI without your written authorization, or
an opportunity to object, in certain circumstances, and unless prohibited by a more stringent
state law, including:
For treatment, payment or health care operations activities or another healthcare
provider.
For healthcare and legal compliance activities.
For healthcare fraud and abuse detection or other activities related to compliance with
the law.
To a family member, or other relatives, or close personal friend or other individual
involved in your case if we obtain your verbal agreement to do so or if we give you an
opportunity to object to such a disclosure and your do not raise in objection, and in certain other
circumstances where we are unable to obtain your consent and believe the disclosure is in your
best interests.
For Health Oversight activities including audits or government investigations, County
Medical Control reviews, inspections, disciplinary proceedings, and other administrative or
judicial actions under-taken by the government (or their contractors) by law to oversee the
health care system.
For judicial and administrative proceedings required by court or administrative order, or
in response to a subpoena or other legal process.
For law enforcement activities in certain limited circumstances, such as where there is a
warrant or the information is needed to locate a suspect or respond to a crime.
For coroners, medical examiners, and funeral directors to identify a deceased person,
determine cause of death, or otherwise carry out their duties.
For organ donation activities, if you are a donor, in a manner necessary to facilitate the
donor process.
For research after an institutional review board has reviewed the research proposal and
protocols to ensure the privacy of your PHI and has approved the research.

 For preventing or lessoning the imminent threat to the health or safety of a person or the
public in accordance with federal and state laws. We may also use and disclose your PHI to law
enforcement officers and agencies to apprehend an individual who participated in a violent crime
or escaped from lawful custody.
For military activities, national defense and security, or other governmental functions.
For compliance purposes with Workers Compensation laws and other similar legally
established programs.
For any purpose if the used PHI does not identify you or reveal who you are.
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 by contacting our Billing Department.
PATIENT RIGHTS:

As a patient you have a number of rights with respect to your PHI.

The Right to Access Copy or Inspect Your PHI.

o 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, as state
law permits, to provide a copy of any medical information you have the 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 forms available
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.
The Right to Receive Confidential Communications of Your PHI.
o If you wish to inspect or obtain a copy of your medical information, you should
contact our local privacy representative.

The Right to Copy of PHI Maintained in an Electronic Format.

o If we use or maintain an electronic health record with respect to your PHI you have
a right to obtain a copy of that PHI in an electronic format and, if you choose, to
have us transmit a copy directly to an entity or person you clearly, conspicuously,
and specifically designate

The Right to Amend Your PHI.

o You have the right to ask us to amend written medical information 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 you have asked us to amend is
correct. If you wish to request an amendment of the medical information we have
about you, please contact our local privacy representative to obtain an amendment
request form.

The Right to Request an Accounting.

o You may request an accounting from us of certain disclosures of your medical
information we have made in the six years prior to the date of your request.
However, your requests for an accounting of disclosures cannot precede the
implementation date of HIPAA March 22, 2004. We are not required to give you an

accounting of information we have used or disclosed for purposes of treatment,

payment or health care operations, or when we share your health information with
our business associates such as our billing company or a medical facility from/to
which we have transported you. We are also not required to give you an accounting
of our uses of PHI for which you have already given us written authorization. If you
wish to request an accounting, contact our local privacy representative.

The Right to Request That We Restrict the Uses and Disclosures of Your PHI.
o You have the right to request that we restrict how we use and disclose your medical
information we have about you. We are not required to agree to any restrictions you
request, but any restrictions agreed to by us in writing are binding on us.

The Right to Restrictions on Disclosures to Health Plans for Services Paid In Full
Out of Pocket.
o Except as otherwise required by law, at your request we will not disclose your PHI to
a health plan for purposes of carrying out payment or health care operations (and is
not for the purpose of carrying out treatment), if the PHI pertains solely to a health
care item or service for which we have been paid out of pocket in full.

Right to Request Alternative Communications.

o You have the right to request that we communicate with you about medical matters
in a certain way or at a certain location. For example, you can ask that we only
contact you at work or by mail. To request confidential alternative communications,
you must make your request in writing on the form provided by the Practice. We will
not ask you the reason for your request. We will accommodate all reasonable
requests. Your request must specify how or where you wish to be contacted.

Internet and the Right to Obtain a Paper Copy of the Notice on Request.
o If we maintain a web site, we will prominently post a copy of this Notice for your
review. We will always provide you a paper copy of the Notice upon request.

The Right to Opt Out of Fundraising.

o In the event that Patriot would contact you to request your participation in fund
raising efforts, you have the right to opt out of receiving such communications.

The Right to Pay Out of Pocket.

o You have the right to request restrictions of disclosures of your PHI to health plans if
you consent to pay the balance for services in full.

Your Legal Rights and Complaints.

o 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 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 official.

Revisions to the Notice:

o Patriot Ambulance Service 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 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 can get a copy of the
latest version of this Notice by contacting our privacy official.

Privacy Officer Contact Information:

Patriot Ambulance Service, Inc.
ATTN: Privacy Officer
5189 Commerce Rd
Flint, MI 48507

Patriot Ambulance Service, Inc. reserves the right to change the terms or this notice at any time, and the
changes will be effective immediately and will pertain to all PHI that we maintain.

Effective:

02/01/2015