 | CITY OF JACKSONVILLE, ALABAMA HIPAA PRIVACY POLICY NOTICE |
This Notice describes our Privacy Policy, describes your rights, and describes how your health information may be used and disclosed to others. Please review it carefully. Your health and your privacy are our concern.
Our City wishes to inform you of your rights regarding your private health care information. You have the right to review our privacy policy prior to signing the
Acknowledgement of Receipt form. By signing this notice, you acknowledge that you have had the opportunity to review our Privacy Policy and have been given a copy to keep. In the event that our policy changes, you may contact us at 320 Church Avenue, SE, Jacksonville, AL 36265.
You also have the right to request that we restrict the method in which we use or disclose your health information for purposes of treatment, payment or other health care operations. We have the right to refuse to comply with your request.
By signing this form, you expressly acknowledge our use and disclosure of your health information for purposes of treatment, payment or other health care operations. This notice will not expire and will apply to services provided to you from this day forward.
We will keep and record information about your medical condition. We may use this information or disclose this information to others as follows:
- We may use or disclose your health information in order to treat you. For example, we may advise the health care provider to which we are transporting you of your medical condition, including your vital signs and medications we may have administered to you. We may also disclose your medical condition to family or caregivers who are involved in your medical care.
- We may use or disclose your health information in order to receive payment for the services we provide to you. For example, we may disclose your condition in order for your insurance company to understand why you received treatment so that they will pay your claim. We may also disclose your information to our billing department/billing company/attorney in order to seek payment for the services we provided to you.
- We may use or disclose your health information for our operations. For example, we may review your information in order to evaluate your treatment and our services in order to insure that our care for you now and in the future is the best that it can be. We may use your health information to contact you in the future. We may also disclose your information as required by law.
You have the following rights regarding your health information:
- The Right to Inspect and Copy Your Information. You may review and copy your medical records and information
- The Right to Amend. You may ask that we amend your health information if you believe that your information is incomplete or incorrect. A request for an amendment should be made in writing and should be sent to us at the above address. Your request must be accompanied by a statement from you regarding why you feel the amendment is proper. We may deny your request if it is not written or if you fail to state a reason for the proposed amendment. We may also deny your request if you ask us to amend information that is not part of the information we keep, was not created by us (unless the entity responsible is no longer available), is not part of the information available for you to inspect and copy, or is accurate and complete.
- The Right to Know About Disclosures. You have the right to request an accounting of to whom we have disclosed your health information. This request should be made in writing and sent to us at the above address. You must state a time period for your request, which can not be longer than six (6) years. Your request every 12 months is free. After that we may charge you for additional requests made within 12 months of your last request.
- Right to Request Restrictions. You may request a restriction or limitation on how and what health information we disclose regarding you for treatment, payment or health operations to your family or caregivers. We do not have to agree to your request. Requests for restrictions must be made in writing and sent to us at the address on this form. Your request must include a statement of what information you want to limit, how you want it limited, and to whom you want the limits to apply.
- Right to Confidential Communications. You may request that we communicate with you about medical matters in a certain format or at a specific location. You must request such a confidential communication or specific type or place of communication in writing, submitted to us at the address on this form. No reason for this request is necessary, and we will honor all reasonable requests.
- Right to Receive a Copy of This Notice. You may request and receive a written copy of this notice (or our current notice) at any time by contacting us at the address on this form.
Please note that we retain the right to alter, amend or change this notice at any time. Any such revision may be effective on any information we obtain about you in the future or any information that we may have regarding you. A copy of our most current Notice will be on display in our office.
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