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.
Each time a patient contact is made and treatment is provided, Kingman Fire Department (hereinafter
referred to as KFD) a healthcare provider, a record is made which typically contains your symptoms, exam, condition, and
KFD is required by law to ensure that medical information that identifies you is kept private and to
provide you this notice as to our legal duties and privacy practices with respect to medical information about you, and
to abide by the terms of this notice.
KFD may release medical information about you for worker’s compensation or similar programs. These
programs provide benefits for work related injuries or illness.
KFD may release medical information if asked to do so by a law enforcement official:
In response to a court order, subpoena, warrant, summons or similar
To identify or locate a suspect, fugitive, material witness or
About the victim of a crime if, under certain limited circumstances,
we are unable to obtain the person’s agreement.
About a death we believe may be the result of criminal conduct.
In emergency circumstances to report a crime, the location of the
crime or victims, or the identity, description or location of the person who committed the crime.
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 military, national defense and security and other special
To avert a serious threat to health and safety of a person or the
public at large.
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.
We may also use or disclose health information about you in a way that does not personally identify you
or reveal who you are, such as gathering statistical data.
Additionally, patient information will be provided to an Attorney provided that the request for
information is received on Attorney letterhead and is accompanied by a signed authorization from the patient.
You have the right to request a restriction on certain uses and disclosures of your information except
those uses and disclosures that we are legally required or allowed to make. Other uses and disclosures will be made only
with your written authorization and you may revoke such authorization except to the extent that action has already been
taken based on that authorization. You have the right to get a list of uses and disclosures KFD has made other than
those purposes of quality assurance and compliance with the laws that affect KFD.
You have the right to ask that we send information to you to an alternate address or by alternate means.
KFD must agree to your request so long as we can easily provide it in the format you requested.
You have the right to see and receive copies of your medical information we have in our possession, but
you must make the request in writing. If we don’t have your medical information, but we know who does, we will tell you
how to obtain it. We will respond to you within 30 days after receiving your written request. The signature on your
written request must be notarized.
You have the right to have KFD amend a record about you in a designated record for as long as the
protected health information is maintained. However, we may deny your request for amendment if we determine the record
that is the subject of your request was not created by KFD, unless you provide a reasonable basis to believe that the
originator of the record is no longer available to act on the requested amendment, is not part of the designated record
set; would not be available to you for inspection under right of access; or is accurate and complete. You must make the
request for amendment in writing and provide a reason to support the requested amendment.
KFD reserves the right to change this notice. We will post a copy of the current notice in the
Administrative Office and at each of our fire stations.
Any other use or disclosure of private health information, 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.
If you believe your privacy rights have been violated, you may file a complaint with KFD at the address
below or with the:
Secretary of the Department of Health and Human Services
200 Independence Ave. SW.
Washington, D.C. 20201
You will not be retaliated against for filing a complaint.
KFD reserves the right to change the terms of this notice and to make new notice provisions effective for
all private health information KFD maintains. A current notice will be posted on the city’s website and available at KFD
Administration Office at:
Kingman Fire Department
412 E. Oak Street
Kingman, AZ 86401
For mailing address please use:
Kingman Fire Department
310 N. 4th Street
Kingman, AZ 86401
For further information you may contact the Privacy Officer, Battalion Chief Bill Johnston by phone at
(928)753-2891 or by e-mail at firstname.lastname@example.org