This notice will tell you how we may use and disclose protected health information about you. Protected Health Information means any health information about you that identifies you or for which there is a reasonable basis to believe the information can be used to identify you. In this notice, we call all of that Protected Health Information, medical information.

This notice also will tell you about your rights and our duties with respect to medical information about you. In addition, it will tell you how to complain to us if you believe we have violated your privacy rights.

How We May Use and Disclose Medical Information We use and disclose medical information about you for a number of different purposes. Each of those purposes is described below.

For Treatment We may use medical information about you to provide, coordinate or manage your health care and related services by both us and other healthcare providers. We may disclose medical information about you to doctors, nurses, hospitals, and other health facilities who become involved in your care. We may consult with other health care providers concerning you as a part of the consultation; share your medical information with them. Similarly, we may refer you to another health care provider and as part of the referral, share medical information about you with that provider. For example, we may conclude your need to receive services from a physician’s office and provide medical information about you to them so they have information they need to provide services for you.

For Payment We may use and disclose medical information about you so we can be paid for the services we provide you. This can include billing you, your insurance company, or a third-party payer. For example, we may need to give your insurance company information about the healthcare services we provide to you so your insurance company will pay us for those services or reimburse you for amounts you have paid. We also may need to provide your insurance company or a government program, such as Medicare or Medicaid, with information about your medical condition and the health care you need to receive to obtain a determination if you are covered by that insurance or program.

For Health Care Operations We may use and disclose medical information about you for our own health care operations. These are necessary for us to operate Agency Medical Services, and to maintain quality healthcare for our patients.  For example, we may use medical information about you to review the services we provide and the performance of our employees in caring for you. We may disclose medical information about you to train our staff, volunteers and students working in Agency Medical Services.  We also may use the information to study ways to more efficiently manage our organization. Disagreement if any, and or rebuttal, if any will then be appended to the medical information involved or otherwise linked to it. All of that then will be included with any subsequent disclosure of the information, or at our election, we may include a summary of any of the information.

If you do not submit a statement of disagreement, you may ask that we include your request for amendment and our denial with any fixture disclosures of the information. We will include your request for amendment and our denial (or a summary of that information) with any subsequent disclosure of the medical information involved.

You Have the Right to Complain or Deny Your Request

Right to an Accounting of Disclosures(s) You have the right to receive an accounting of disclosures of medical information about you. The accounting may be for up to six (6) years prior to the date on which you request the accounting but not before June 1, 2005.

Certain types of disclosures are not included in such an accounting: Disclosure: • To carry our treatment, payment and health care operations • Of your medical information made to you • That You are incident to another use or disclosure • Disclosures you have authorized • For national security or intelligence purposes • To correctional institutions or law enforcement officials having custody of you • Disclosures that are part of a limited data set for purposes of research, public health or health care operations (a limited data set is where things that would directly identify you have been removed) • Disclosures made prior to June 1, 2005

Under certain circumstances your right to an accounting of disclosures to a law enforcement official or a health oversight agency may be suspended. Should you request an accounting during the period of time your right is suspended, the accounting would not include the disclosures to a law enforcement official or to a health oversight agency.

To request an accounting of disclosures, you must submit in writing a “request” to: Agency Medical

Services.  Attention: PCS Program Manager

Your request must state a time period for the disclosures. It may not be longer than six years from the date we receive your request.

Usually, we will act on your request within 60 calendar days after we receive your request. Within that time, we will either provide the accounting of disclosures to you or

Give you a written statement of when we will provide the accounting and why the delay is necessary.

There is no charge for the first accounting we provide to you in any twelve-month period. For additional accountings we may charge you for the cost of providing the list. If there is a charge, we will notify you of the costs involved and give you an opportunity to withdraw or modify your request to avoid or reduce the fee.

Right to a Copy of this Notice You have a right to obtain a paper copy of our Notice of Privacy Practices. You may request a copy of this notice at any time.