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Original 4-14-2003, revised 7-14-2014


Protected Health Information is information about you that may identify you and that relates to your past, present, or future physical or mental health or condition, your treatment, or payment for your healthcare. We are required by law to maintain the privacy of your potential health information and to provide you with this Notice of Privacy Practices and our duties to you. We reserve the right to change the terms of this notice.

 1. Uses and Disclosures of Protected Health Information

We are permitted to use and disclose protected health information for care and treatment in order to provide healthcare services to you. We may also use your protected health information for payment of your healthcare bills. The following are examples of the ways that we are permitted to use your medical information for treatment, payment and healthcare operations. These examples are not exhaustive, but are used to illustrate the types of uses or disclosures that might be made.


We will use and disclose your protected health information to provide you with medical treatment services. We may disclose information about you to Doctors, Nurses, Technicians, Students, and other personnel who are involved in your care.


We will use your protected health information insurance company or a third Party.

Healthcare Operations:

We will use medical information about you as needed to ensure a high quality of care for our patients. We may use medical information about you to review and evaluate the performance of our staff. Other activities for which we may use or disclose information include but are not limited to training programs, auditing, business management and planning, and administrative functions.

 2. Other permitted uses and disclosures and your opportunity to object

You may agree or object to the use or disclosure of all or part of your protected health information for these purposes.

Disaster Relief: We may disclose medical information about you to an entity assisting in a disaster relief effort.

 3. Uses and disclosures we are allowed to make without your permission or opportunity to object

                Required by law:

We will use your medical information when required by federal, state, or local law. The use of this disclosure will be limited to what is required by law.

                Abuse, Neglect, or Domestic Violence:

We may disclose your protected health information to a public health authority that is        authorized to receive reports of neglect or abuse. In addition we may disclose information to an authorized agency if we believe you have been the victim of abuse or neglect. Disclosure will be consistent with state and federal regulations.


We may disclose information about an inmate to a correctional institution or law enforcement officer as authorized by law.

                Workers compensation:

We may disclose your protected health information to comply with workers compensation laws and other similar programs established by law.

 4. Uses and Disclosures made only with written authorization

If you provide us with your written permission to use or disclose information about you, you may revoke the authorization at any time, in writing. If you wish to revoke a written authorization, contact our privacy officer.

 5. Your rights and how to Exercise Them


You have the right to request restrictions on certain uses and/or disclosures of protected health information, although we are not required to agree to the restriction unless the patient pays out of pocket, in full for services received.


You have the right to inspect and or receive a copy of your protected health information, the right of electronic access to and the right to request protected health information to be transmitted to a third party. Psychotherapy notes, information compiled in anticipation of civil, criminal, or administrative action or proceedings and information subject to the Clinical Laboratory Improvement Act (CLIA) are excluded from access rights.


You have the right to request an amendment to your protected health information.


You have the right to have an accounting of disclosures of you protected health information.

     Copy of notice:

You have the right to receive a paper copy of this Notice of Privacy Practices even if you request one to be sent electronically.

 6. Complaints

If you believe your privacy rights have been violated, you may file a complaint with us by notifying our Privacy Officer. You may also file a complaint with the Secretary of Health and Human Services. We will not retaliate against your for filing a complaint.

If you have any questions concerning this notice you may contact Cape County Private Ambulance in writing at:

Cape County Private Ambulance Service, Inc.                                                                                         1458 N. Kingshighway                                                                                                                              Cape Girardeau, MO 63701

or call our office during normal business hours at 573-335-2191.