Privacy Practices

Effective: June 1, 2011/ Revised: September 10, 2014
Excelsior Ambulance Service, Inc.


Excelsior is required by law to maintain the privacy of your health
information and to provide you with notice of Excelsior’s legal duties and
privacy practices with respect to your health information. .Under certain
circumstances, Excelsior Ambulance Service may be required to notify
patients regarding a breach of unsecured protected health information (PHI).
Excelsior is required to abide by the terms set forth in this notice. We
reserve the right to change this notice and to make the changed notice
effective for medical information we already have about you as well as any
information we receive in the future.  We will provide a revised copy of this
notice to you upon your request.

Excelsior may use your health information for the purposes of providing
medical treatment, obtaining payment for services rendered, and/or
administering health care operations, as well as for the purposes set forth
in this notice or otherwise as authorized or required by law.  Excelsior will
restrict access to your health information to persons who are directly
involved in those functions.  All other uses and disclosures of your health
information will not be made without your authorization, which you may
revoke by providing Excelsior with a written notice. The law also requires
your written authorization before we may use or disclose: (a) psychotherapy
notes, other than for our treatment, payment or healthcare operations
purposes, (b) any PHI for our marketing purposes or (c) any PHI as part of
sale of PHI.  Some examples of how Excelsior may use and disclose your
health information are:
A.  Uses and Disclosures For Treatment:  For example, a paramedic who is
directly involved in your treatment must and shall be allowed access to
your health information as well as be permitted to share it with another
paramedic, a medical director or Excelsior personnel who participates in
your treatment.  We may use and disclose medical information about you
when necessary to prevent a serious threat to your health and safety or the
health and safety of the public or another person.  Any disclosure,
however, would only be to someone able to help prevent the threat.
B.  Uses and Disclosures For Payment:  For example, we may give your
health plan, or other payer, your medical information in order to identify the
treatment, bill for services or receive payment.  We also may disclose your
health information to another covered entity or a health care provider for
their payment activities.
C.  Uses and Disclosures For Health Care Operations:  These types of
uses and disclosures of your health information are necessary to run the
ambulance company and make sure that all of our Patients receive quality
services.  For example, we may use medical information about you to
review our treatment procedures and to evaluate the performance of our
staff.  We may also disclose your health information to another health care
provider for its health care operations, provided they have or had a direct
relationship in your care, and to government regulators.
D.  Other Permitted Uses and Disclosures:  Excelsior may use or disclose,
prohibit or restrict, the use or disclosure to a family member, other relative,
a close personal friend, or anyone identified by you who is involved in your
medical care or payment for your care.  If you do not have the opportunity
to agree or object to such use or disclosure because you are not present
or because of your incapacity or emergency circumstances, Excelsior may,
in the exercise of professional judgment and its experience with common
practice, determine whether the disclosure is in your best interest and, if so,
disclose health information that is directly relevant to that person’s
involvement with your care.

  1. Your Rights with Respect to Your Health InformationA.  Your Right to Inspect and Copy:  You have the right to inspect and copy
    your health information that may be used to make decisions about your
    care.  If you are a parent or legal guardian of a Patient, you may also
    obtain a copy of the health care information of your non-emancipated child
    (ren), except where prohibited by law for specific health care services.
    Requests for copies of your health information must be made in writing to
    Excelsior’s Business Office at the address in paragraph “H” of this Notice.
    Such requests must be made on Excelsior’s “Medical Authorization” release
    form, which may be obtained from the Business Office.  Requests must
    include the notarized signature of the Patient, or the Patient’s parent or
    legal guardian in the event that the Patient is a non-emancipated minor.
    We may deny your request to inspect and copy in limited circumstances.  If
    you are denied access to medical information, you may request that the
  2. Your Right to Request Amendments:  If you feel that medical information
    about you is incorrect or incomplete, you may ask us to amend the
    information.  You have the right to request an amendment for as long as
    the information is kept by or for Excelsior.  To request an amendment, your
    request must be made in writing and submitted to the Business Office.  You
    must provide a reason that supports your request. We may deny your request
    for an amendment if it is not in writing or does
    not include a reason to support the request.  In addition, we may deny your
    request if you ask us to amend information that:  (a) was not created by
    Excelsior, unless the person or entity that created the information is no
    longer available to make the amendment; (b) is not part of the medical
    information kept by or for Excelsior; (c) is not part of the information that
    you would be permitted to inspect and copy; or (d) is accurate and
    C.  Your Right to Request Restrictions:  You have the right to request a
    restriction or limitation on the medical information we use or disclose about
    you.  We are not required to agree to your request.  If we do agree, we will
    comply with your request unless the information is needed to provide you
    with emergency treatment.  We must, however, agree to a restriction on the
    use or disclosure of your PHI if: (a) the disclosure is for our payment or
    healthcare operations purposes and (b) if you or another person acting on
    your behalf has paid for our services in full.  To request restrictions, you
    must make your request in writing to the Business Office.  Such requests
    must include the information you want to limit; whether you want to limit our
    use, disclosure, or both; and the person(s) to whom you want these limits to
    apply (e.g., disclosures to your family).
    D.  Your Right to Request Confidential Communications:  You have the
    right to request that we communicate with you regarding medical matters in
    a certain way or at a certain location.  For example, you can ask that we
    only contact you at work or by mail.  To request confidential
    communications, you must make your request in writing to the Business
    Office.  We will accommodate all reasonable requests.  Your request must
    specify how or where you wish to be contacted.
    E.  Your Right to an Accounting of Disclosures:  You have the right to
    request a list of the disclosures we made of your health information for
    purposes other than treatment, payment or health care operations.  To
    request a list of disclosures, you must submit your request in writing to the
    Business Office.  Your request must state a time period which may not be
    longer than six (6) years and may not include dates before June 1, 2011.  Your
    request should indicate in what form you want the list.  The first list you
    request within a twelve (12) month period will be free.  For additional lists,
    we may charge you for the costs of providing the list.  We will notify you of
    the cost involved and you may choose to withdraw or modify your request
    at that time before any costs are incurred.
    F.  Your Right to a Paper Copy of This Notice:  You may ask us to give you
    a copy of this notice at any time.  Even if you agreed to receive this notice
    in electronic form, you may receive a paper copy upon request.  You may
    also obtain a copy of this notice at our website,  To
    obtain a paper copy of this notice, you must submit your request in writing
    to Excelsior’s Business Office.
    G.  Complaints:  If you believe your privacy rights have been violated, you
    have the right to file a complaint with Excelsior and with the Secretary of
    Health and Human Services.  To file a complaint with Excelsior, send it in
    writing to:  Excelsior Ambulance Service, 108 Polly Ogden Lane Baxley, GA
    31513 Attn:  Designated Privacy Administrator.  All complaints must be
    received in writing.  Excelsior does not have a process in place for verbal
    complaints.    You will not be penalized or discriminated against for filing a
    H.  Designated Privacy Administrator:  Requests for further information
    should be addressed to

Excelsior Ambulance Service
Attn: Designated Privacy Administrator
108 Polly Ogden Lane
Baxley, GA 31513