Green Bay Fire Department
Ambulance Billing Information
Service Address:
Green Bay Fire Department
501 S. Washington St.
Green Bay, WI 54301-4218
Billing Performed By:
EMS Medical Billing Associates, LLC
9401 W. Brown Deer Rd, Suite 101
Milwaukee, WI 53224
Office Number 1-866-950-4400
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.
The Green Bay Fire Department and EMS Medical Billing Associates will only use your personal health information to obtain accurate payment for services rendered.
1. PROTECTING YOUR PRIVACY.
It is your right as a patient to be informed of the privacy practices of the Green Bay Fire Department, as well as to be informed of your privacy rights with respect to your personal health information. This notice of privacy practices is intended to provide you with this information. Please note the language herein refers to the Green Bay Fire Department includes both the Green Bay Fire Department and our medical billing service, EMS Medical Billing Associates.
EMS Medical Billing Associates is authorized by the Green Bay Fire Department to respond to any requests, concerns or questions regarding this policy or the use of your personal health information as it relates to obtaining insurance payment or other health care operations. Please call EMS Medical Billing Associates at the number listed above.
2. THE GREEN BAY FIRE DEPARTMENT’S RESPONSIBILITIES.
The Green Bay Fire Department is required to:
Maintain the privacy of your health information;
Provide you with a notice of the legal duties and privacy practices regarding protected health information collected and maintained about you.
Abide by the terms of this notice.
The Green Bay Fire Department reserves the right to change the terms of the notice of privacy practices and make the new notice provisions effective for all protected health information that it maintains. The Green Bay Fire Department also reserves the right to change the terms of its notice with respect to any applicable uses and disclosures.
The Green Bay Fire Department will promptly revise and distribute its privacy practices policy whenever a substantial change is made to any of its privacy practices.
The Green Bay Fire Department will not use or disclose your health information without your authorization, except as described in this policy.
3. YOUR HEALTH INFORMATION RIGHTS.
You have a right to:
Request restrictions on certain uses and disclosures of protected health information, even if the restriction affects your treatment or the Green Bay Fire Department’s payment or health operations activities. However, the Green Bay Fire Department is not required to agree to your requested restriction.
Request that the Green Bay Fire Department communicate your health information to you. The Green Bay Fire Department’s billing service, EMS Medical Billing Associates, will accommodate any reasonable request. You may inspect and obtain a copy of your health record. This request for access to your health care record must be submitted to EMS Medical Billing Associates, in writing to the compliance officer, with a consent signed by the patient or the patient’s power of attorney or personal representative. You may make one request per year at no charge. EMS Medical Billing Associates may charge a reasonable fee for additional copies of your health care record.
Request an amendment to your health care record if you believe the health information is incorrect or incomplete as documented by the Green Bay Fire Department. You must make this request, in writing, to the compliance officer at EMS Medical Billing Associates. You must state the reason why your health record should be changed. If the Green Bay Fire Department did not create the record or disagrees with your requested change, your request may be denied.
Obtain an accounting of disclosures of your health information that the Green Bay Fire Department has made in compliance with state and federal law. The accounting can be requested in writing to EMS Medical Billing Associates. They will describe the dates of each disclosure, a brief description of information disclosed and the reason for disclosure. You may request one accounting per year at no charge. EMS Medical Billing Associates may charge a reasonable fee for additional copies of your accounting disclosures.
Obtain a paper copy of EMS Medical Billing Associates’s Privacy Practices Policy, at no charge, by contacting the number listed above.
4. USES AND DISCLOSURES FOR TREATMENT, PAYMENT AND HEALTH CARE OPERATIONS.
The Green Bay Fire Department is permitted by federal privacy rule to use or disclose your protected health information for treatment, payment or health care operations.
The Green Bay Fire Department may use or disclose your health information:
In the provision, coordination or management of your healthcare.
To obtain reimbursement for the provision of health care services provided. The bill may include information that identifies you, your diagnosis and your treatment.
For evaluation of patient care services, evaluating the performance of the EMT staff, business budgeting projections and activities such as internal audits that relate to compliance with the laws that regulate our operations.
5. USES OR DISCLOSURES OF YOUR PROTECTED HEALTH INFORMATION PERMITTED WITHOUT YOUR AUTHORIZATION.
Without your written authorization, the Green Bay Fire Department may use or disclose your health information as required by law. This includes information pertaining to a worker’s compensation claim, to injury for victims of abuse, neglect, or domestic violence, for judicial proceedings, for law enforcement purposes, for statutory reporting to the State of Wisconsin for public health safety, in response to a request by a state or federal agency, for activities related to death, tissue donation, or to avert a serious threat to health or safety.
Effective Date: This Notice of Privacy Practices is effective as of 04/01/03
