In emergency situations, it may be beneficial should emergency responders know of particular disability information prior to arriving at your home. The information shall be maintained in the 9-1-1 computer aided dispatch system.  The information is conveyed to emergency responders at the time of dispatch to your address.  The information alerts rescuers to situations in which you, or other occupants, may have difficulty in exiting the building or describe another functional limitation or situation you wish to include.  Should you desire to have this type of information available to emergency responders, please complete this form and submit it to:

DISABILITY SERVICES, VILLAGE OF ARLINGTON HEIGHTS, 33 S. ARLINGTON HEIGHTS RD., ARLINGTON HEIGHTS, IL 60005. 

For more information please call (847) 368-5793. 

  
Detailed medical information about yourself, or other individuals that reside with you, can be maintained by utilizing the separate “Emergency Information” Packet (Red Label). This packet should be affixed to your refrigerator, and contains forms regarding your health and other medical history. When the Fire Department arrives at your home for a medical emergency, the “Emergency Information” Packet is extremely valuable if you are unable to communicate with emergency personnel.

Contact the Disability Services Coordinator at the above address for additional information. 

The Village of Arlington Heights (“Village”) 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.  The Village is also required to abide by the terms of the version of this Notice currently in effect.  
Uses and Disclosures of PHI: The Village may use PHI for the purposes of treatment 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, telephone, internet or fax 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.  The Village is permitted to use PHI without your written authorization, or opportunity to object, in certain situations, and unless prohibited by a more stringent state law, including: 

• For the treatment or health care operations activities of another health care provider who treats you;
• For health care and legal compliance activities;
• To a family member, other relative, or close personal friend or other individual involved in your care if we obtain your verbal agreement to do so or if we give you an opportunity to object to such a disclosure and you do not raise an objection, and in certain other circumstances where we are unable to obtain your agreement and believe the disclosure is in your best interests;
• To a public health authority in certain situations as required by law (such as to report abuse, neglect or domestic violence);
• For health oversight activities including audits or government investigations, inspections, disciplinary proceedings, and other administrative or judicial actions undertaken by the government (or their contractors) by law to oversee the health care system;
• For judicial and administrative proceedings as required by a court or administrative order, or in some cases in response to a subpoena or other legal process;
• For law enforcement activities in limited situations, such as when responding to a warrant;
• For military, national defense and security and other special government functions;
• To avert a serious threat to the health and safety of a person or the public at large;
• For workers’ compensation purposes, and in compliance with workers’ compensation laws;
• To coroners, medical examiners, and funeral directors for identifying a deceased person, determining cause of death, or carrying on their duties as authorized by law;
• If you are an organ donor, we may release health information to organizations that handle organ procurement or organ, eye or tissue transplantation or to an organ donation bank, as necessary to facilitate organ donation and transplantation;
• For research projects, but this will be subject to strict oversight and approvals;
• 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 only be made 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 you may appeal certain types of denials.  We have available forms to request access to your PHI and we will provide a written response if we deny you access and let you know your appeal rights.  You also have the right to receive confidential communications of your PHI.  If we maintain your medical information in electronic format, then you have a right to obtain a copy of that information in electronic format.  If you wish to inspect and copy your medical information, you should contact our Privacy Officer.   

The right to amend your PHI. You have the right to ask us to amend written medical information that we may have about you. We will generally amend your information within 60 days of your request and 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. If you wish to request that we amend medical information that we have about you, contact our Privacy Officer.  

The right to request an accounting.  You may request an accounting from us of certain disclosures of your medical information that we have made in the six years prior to the date of your request.  We are not required to give you an accounting of information we have used or disclosed for purposes of treatment or health care operations, or when we share your health information with our business associates, like a medical facility from/to which we have transported you.  We are also not required to give you an accounting of our uses of protected health information for which you have already given us written authorization.  If you wish to request an accounting, 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 your medical information that we have about you.  The Village is not required to agree to any restrictions you request, but any restrictions agreed to by us in writing are binding.  However, if the information you ask us to restrict is needed to provide you with emergency treatment, then we may disclose the PHI to a healthcare provider to provide you with emergency treatment. 

The right to notice of a breach of unsecured protected health information.  If there is a breach of unsecured PHI we will notify you by first class mail sent to the most recent address we have on file.  If you prefer to be notified about breaches by electronic mail, please contact the Privacy Officer.  You may also withdraw your agreement to receive notice by e-mail at any time by contacting the Privacy Officer. 

Internet, Electronic Mail, and the Right to Obtain Copy of Paper Notice on Request. You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. Please make any such request in writing specifying how or where you wish to be contacted. We will accommodate reasonable requests.
   
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:  The Village 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:  
Privacy Officer, Legal Department, Village of Arlington Heights, 33 South Arlington Heights Road, Arlington Heights, Illinois 60005; 847/368-5000  
Effective Date of the Notice:  March 9, 2011- Revised September 23, 2013