The following information is included in the signature authorization statement signed by you or your authorized representative at the time of service:
Assignment of Insurance Benefits: I request that payment of authorized Medicare, Medicaid, or any other insurance benefits be made on my behalf to Greenville Rescue Squad Inc. for any services provided to me by Greenville Rescue Squad Inc. now, in the past or in the future. I understand that I am financially responsible for the services and supplies provided to me by Greenville Rescue Squad Inc., regardless of my insurance coverage, and in some cases, may be responsible for an amount in addition to that which was paid by my insurance. I agree to immediately remit to Greenville Rescue Squad Inc. any payments that I receive directly from insurance or any source whatsoever for the services provided to me and I assign all rights to such payments to Greenville Rescue Squad Inc. I authorize Greenville Rescue Squad Inc. to appeal payment denials or other adverse decisions on my behalf without further authorization. I authorize and direct any holder of medical information or documentation about me to release such information to Greenville Rescue Squad Inc. and its billing agents, the Centers for Medicare and Medicaid Services and its carriers and agent, and/or any other payers or insurers as may be necessary to determine these or other benefits payable for any services provided to me by Greenville Rescue Squad Inc., now, in the past or in the future. A copy of this form is as valid as an original.
Greenville Rescue Squad inc.
Greenville Rescue Squad, Inc.
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.
Greenville Rescue Squad, Inc. (GRS) is required by law to maintain the privacy of certain confidential health care information, known as Protected Health Information or PHI, and to provide you with a notice of our legal duties and privacy practices with respect to your PHI. GRS is also required to abide by the terms of the version of this Notice currently in effect.
Uses and Disclosures of PHI: GRS may use PHI for the purposes of treatment, payment, and health care operations, in most cases without your written permission. Examples of our use of your PHI:
For Treatment: This includes such things as obtaining verbal and written information about your medical condition and treatment from you as well as from 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.
For Payment: This includes any activities we must undertake in order to get reimbursed for the services we provide to you, including such things as submitting bills to insurance companies, making medical necessity determinations, and collecting outstanding accounts.
For Health Care Operations: This includes quality assurance activities, licensing, and training programs to ensure that our personnel meet our standards of care and follow established policies and procedures, as well as certain other management functions.
Use and Disclosure of PHI without Your Authorization: GRS is permitted to use PHI without your written authorization, or opportunity to object, in certain situations, and unless prohibited by a more stringent state or federal law, including:
We may also use or disclose health information about you in a way that does not personally identify you or reveal who you are.
Any other use or disclosure of PHI, other than those listed above will be made only 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.
Patient Rights: As a patient, you have a number of rights with respect to your PHI, including:
The right to access, copy, or inspect your PHI: 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 for you to copy any medical information that you have the right to access. In limited circumstances, we may deny you access to your medical information, and if you disagree with our decision, you may obtain a review of certain types of denials. We have available forms to request access to your PHI. We will provide a written response if we deny you access and let you know your review rights. You also have the right to receive confidential communications of your PHI. To assure your records are discussed and disclosed only to the proper person (you or your legally authorized representative), we normally require you to appear in person at our office to access or discuss your medical information. However, we will honor reasonable requests by you to receive communications about your medical information by alternative means or at alternative locations. If you wish to inspect and copy your medical information, you should contact our Privacy Officer, whose contact information is listed below.
The right to amend your PHI: You have the right to ask us to amend written medical information that we may have about you if you think it is inaccurate or incomplete. 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 and complete. If you wish to request that we amend the medical information that we have about you, you should contact our Privacy Officer.
The right to request an accounting: We are required to keep a record of certain disclosures of your medical information, and you may request an accounting of what that record contains. Disclosures that we are NOT required to keep a record of include:
If you wish to request an accounting of these disclosures, contact our Privacy Officer.
The right to request that we restrict the uses and disclosures of your PHI: You have the right to request that we restrict how we use and disclose the medical information that we have about you. GRS is not required to agree to any restrictions you request, but any restrictions agreed to by GRS in writing are binding on GRS.
Internet, Electronic Mail, and the Right to Obtain Copy of Paper Notice on Request: If we maintain a web site, we will prominently post a copy of this Notice on our web site. If you allow us, we will forward you this Notice by electronic mail instead of on paper and you may always request a paper copy of the Notice.
Revisions to the Notice: GRS 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 protected health information that 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 Officer.
Your Legal Rights and Complaints: 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 Officer.
Privacy Officer Contact Information:
Greenville Rescue Squad, Inc.
P.O. Box 332, Greenville NY 12083
Effective Date of the Notice: April 15, 2021