All forms must be completed-in-full by the patient with the exception of the Physician’s Release which must be completed by the patient’s physician and submitted before a flight can be considered.
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.
- Who We Are This Notice describes the privacy practices of Lifeline, Inc., dba Lifeline Pilots. It applies to your medical information, including your medical record for all services provided to you and by our volunteer pilots.
- Our Privacy Obligations We are required by law to maintain the privacy of your health information (“Protected Health Information” or “PHI”) and to provide you with this Notice of our legal duties and privacy practices with respect to your Protected Health Information. When we use or disclose your Protected Health Information, we are required to abide by the terms of this Notice (or other notice in effect at the time of the use or disclosure). Permissible Uses and Disclosures Without Your Written Authorization In certain situations, which we will describe in Section IV below, we must obtain your written authorization in order to use and/or disclose your PHI. However, we do not need any type of authorization from you for the following uses and disclosures:
- Uses and Disclosures For Treatment, Payment and Flight Operations. We may use and disclose PHI, but not your “Highly Confidential Information” (defined in Section IV.C below), in order to transport you, obtain linked services with other similar organizations, as detailed below: Transport. We use and disclose your PHI to provide appropriate volunteer pilot referral. and other services to you--for example, to diagnose and treat your injury or illness. In addition, we may contact you to provide logistical reminders or information about transport alternatives. We may also disclose PHI to other transportation providers involved in your trip. Transportation Co-ordination. We may use and disclose your PHI for our transport care referral operations, which include internal administration and planning and various activities that improve the quality and effectiveness of the assistance that we arrange for to you. For example, we may use PHI to evaluate the quality of our operations. We may also disclose PHI to your other volunteer pilots when such PHI is required for them to appropriately help you.
- Disclosure to Relatives, Close Friends and Other Caregivers. We may use or disclose your PHI to a family member, other relative, a close personal friend or any other person identified by you when you are present for, or otherwise available prior to, the disclosure, if we (1) obtain your agreement; (2) provide you with the opportunity to object to the disclosure and you do not object; or (3) reasonably infer that you do not object to the disclosure. If you are not present, or the opportunity to agree or object to a use or disclosure cannot practicably be provided because of your incapacity or an emergency circumstance, we may exercise our professional judgment to determine whether a disclosure is in your best interests. If we disclose information to a family member, other relative or a close personal friend, we would disclose only information that we believe is directly relevant to the person’s involvement with your health care or payment related to your health care. We may also disclosure your PHI in order to notify (or assist in notifying) such persons of your location, general condition or death.
- Fundraising Communications. We may contact you to request permission to use elements of your trip in connection with public relations, outreach, development, and educational aspects of Lifeline’s operations.
- Judicial and Administrative Proceedings. We may disclose your PHI in the course of a judicial or administrative proceeding in response to a legal order or other lawful process.
- Law Enforcement Officials. We may disclose your PHI to the police or other law enforcement officials as required or permitted by law or in compliance with a court order or a grand jury or administrative subpoena.
- We may disclose your PHI to a coroner or medical examiner as authorized by law.
- Organ and Tissue Procurement. We may disclose your PHI to organizations that facilitate organ, eye or tissue procurement, banking or transplantation.
- Health or Safety. We may use or disclose your PHI to prevent or lessen a serious and imminent threat to a person’s or the public’s health or safety.
- Specialized Government Functions. We may use and disclose your PHI to units of the government with special functions, such as the U.S. military or the U.S. Department of State under certain circumstances.
- As required by law. We may use and disclose your PHI when required to do so by any other law not already referred to in the preceding categories.
- Uses and Disclosures Requiring Your Written Authorization
- Use or Disclosure with Your Authorization. For any purpose other than the ones described above in Section III, we only may use or disclose your PHI when you grant us your written authorization on our authorization form (“Your Authorization”). For instance, you will need to execute an authorization form before we can send your PHI to your life insurance company or to the attorney representing the other party in litigation in which you are involved.
- Uses and Disclosures of Your Highly Confidential Information. In addition, federal and Illinois law requires special privacy protections for certain highly confidential information about you (“Highly Confidential Information”), including the subset of your PHI that: (1) is maintained in psychotherapy notes; (2) is about mental health and developmental disabilities services; (3) is about alcohol and drug abuse prevention, treatment and referral; (4) is about HIV/AIDS testing, diagnosis or treatment; (5) is about venereal disease(s); (6) is about genetic testing; (7) is about child abuse and neglect; (8) is about domestic abuse of an adult with a disability; or (9) is about sexual assault. In order for us to disclose your Highly Confidential Information for a purpose other than those permitted by law, we must obtain your written authorization.
- Your Rights Regarding Your Protected Health Information
- For Further Information; Complaints. If you desire further information about your privacy rights, are concerned that we have violated your privacy rights or disagree with a decision that we made about access to your PHI, you may contact our Privacy Office. You may also file written complaints with the Director, Office for Civil Rights of the U.S. Department of Health and Human Services. Upon request, the Privacy Office will provide you with the correct address for the Director. We will not retaliate against you if you file a complaint with us or the Director.
- Right to Request Additional Restrictions. You may request restrictions on our use and disclosure of your PHI (1) for treatment, payment and health care operations, (2) to individuals (such as a family member, other relative, close personal friend or any other person identified by you) involved with your care or with payment related to your care, or (3) to notify or assist in the notification of such individuals regarding your location and general condition. While we will consider all requests for additional restrictions carefully, we are not required to agree to a requested restriction. If you wish to request additional restrictions, please request so in writing. We will send you a written response.
- Right to Receive Confidential Communications. You may request, and we will accommodate, any reasonable written request for you to receive your PHI by alternative means of communication or at alternative locations.
- Right to Revoke Your Authorization. You may revoke Your Authorization, Your Marketing Authorization or any written authorization obtained in connection with your Highly Confidential Information, except to the extent that we have taken action in reliance upon it, by delivering a written revocation statement to the Privacy Office identified below.
- Right to Amend Your Records. You have the right to request that we amend Protected Health Information maintained in your medical record file or billing records. If you desire to amend your records, please submit such a request in writing. We will comply with your request unless we believe that the information that would be amended is accurate and complete or other special circumstances apply. In the case of a requested amendment concerning information about the treatment of a mental illness or developmental disability, you have the right to appeal our decision not to amend your Protected Health Information to an Illinois court.
- Right to Receive An Accounting of Disclosures. Upon request, you may obtain an accounting of certain disclosures of your PHI made by us during any period of time prior to the date of your request provided such period does not exceed six years and does not apply to disclosures that occurred prior to April 14, 2003. If you request an accounting more than once during a twelve (12) month period, we will charge you $0.50 per page of the accounting statement.
- Right to Receive Paper Copy of this Notice.
Upon request, you may obtain a paper copy of this Notice, even if you have agreed to receive such notice electronically.
- Effective Date and Duration of This Notice
- Effective Date. This Release shall remain effective for a period of 90 days from the date of signature. Right to Change Terms of this Notice. We may change the terms of this Notice at any time. If we change this Notice, we may make the new notice terms effective for all Protected Health Information that we maintain, including any information created or received prior to issuing the new notice. If we change this Notice, we will post the new on our Internet site at www.lifelinepilots.org. You also may obtain any new notice by contacting the office.
VII. Privacy Office
You may contact the Privacy Office at: Lifeline Pilots 6100 Dirksen Parkway, Suite 302 Peoria, IL. 61607 800-822-7972