.:: Privacy Statement ::.

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.

Effective Date: April 14, 2003
Revision Date: June 6, 2007

Each time a patient contact is made and treatment is provided, Kingman Fire Department (hereinafter referred to as KFD) a healthcare provider, a record is made which typically contains your symptoms, exam, condition, and treatment.

KFD is required by law to ensure that medical information that identifies you is kept private and to provide you this notice as to our legal duties and privacy practices with respect to medical information about you, and to abide by the terms of this notice.

KFD may release medical information about you for worker’s compensation or similar programs. These programs provide benefits for work related injuries or illness.

KFD may release medical information if asked to do so by a law enforcement official:

• In response to a court order, subpoena, warrant, summons or similar process.

• To identify or locate a suspect, fugitive, material witness or missing person.

• About the victim of a crime if, under certain limited circumstances, we are unable to obtain the person’s agreement.

• About a death we believe may be the result of criminal conduct.

• In emergency circumstances to report a crime, the location of the crime or victims, or the identity, description or location of the person who committed the crime.

• 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 health care system.

• For military, national defense and security and other special government functions.

• To avert a serious threat to health and safety of a person or the public at large.

• 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.

We may also use or disclose health information about you in a way that does not personally identify you or reveal who you are, such as gathering statistical data.

Additionally, patient information will be provided to an Attorney provided that the request for information is received on Attorney letterhead and is accompanied by a signed authorization from the patient.

You have the right to request a restriction on certain uses and disclosures of your information except those uses and disclosures that we are legally required or allowed to make. Other uses and disclosures will be made only with your written authorization and you may revoke such authorization except to the extent that action has already been taken based on that authorization. You have the right to get a list of uses and disclosures KFD has made other than those purposes of quality assurance and compliance with the laws that affect KFD.

You have the right to ask that we send information to you to an alternate address or by alternate means. KFD must agree to your request so long as we can easily provide it in the format you requested.

You have the right to see and receive copies of your medical information we have in our possession, but you must make the request in writing. If we don’t have your medical information, but we know who does, we will tell you how to obtain it. We will respond to you within 30 days after receiving your written request. The signature on your written request must be notarized.

You have the right to have KFD amend a record about you in a designated record for as long as the protected health information is maintained. However, we may deny your request for amendment if we determine the record that is the subject of your request was not created by KFD, unless you provide a reasonable basis to believe that the originator of the record is no longer available to act on the requested amendment, is not part of the designated record set; would not be available to you for inspection under right of access; or is accurate and complete. You must make the request for amendment in writing and provide a reason to support the requested amendment.

KFD reserves the right to change this notice. We will post a copy of the current notice in the Administrative Office and at each of our fire stations.

Any other use or disclosure of private health information, 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.

If you believe your privacy rights have been violated, you may file a complaint with KFD at the address below or with the:

Secretary of the Department of Health and Human Services
200 Independence Ave. SW.
Washington, D.C. 20201

You will not be retaliated against for filing a complaint.

KFD reserves the right to change the terms of this notice and to make new notice provisions effective for all private health information KFD maintains. A current notice will be posted on the city’s website and available at KFD Administration Office at:

Kingman Fire Department
412 E. Oak Street
Kingman, AZ 86401

For mailing address please use:

Kingman Fire Department
310 N. 4th Street
Kingman, AZ 86401

For further information you may contact the Privacy Officer, Battalion Chief Bill Johnston by phone at (928)753-2891 or by e-mail at bjohnston@cityofkingman.gov