Ø Right to Inspect and Copy Your Health Information. You may request access to your medical record file and billing records maintained by us in order to inspect and request copies of the records. Under limited circumstances, we may deny you access to a portion of your records. We will comply with the law if the physician says that review of any record would be harmful to your best interest. For example, we may withhold certain portions of a psychiatric record if the physician or psychologist believes that such review of the complete record would be harmful to your best interest.

If you desire access to your medical records, please obtain a record request form from our office and submit the completed form to us. We may charge you a reasonable copying fee in accordance with Virginia State law.

You should take note that if you are a parent or legal guardian of a minor, certain portions of the minor’s medical record will not be accessible to you (for example, records relating to pregnancy, sexually transmitted diseases, substance use or abuse, and/or fertility awareness services).

Ø Right to Amend Your Records. You have the right to request that we amend PHI maintained in your medical record or billing records. If you desire to amend your records, please obtain an amendment request form from our offices and submit the completed form to us. 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, or unless you are requesting us to amend PHI that we maintain, but that we have not authored (i.e., another provider’s records “incorporated” into your record here). We will respond to your request to amend your records within thirty (30) days of receiving the request. We are not required to amend incorporated records, such as records received from another health care facility or provider.

Ø 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 January 1, 2007. If you request an accounting more than once during a twelve (12) month period, we will charge you a reasonable amount for the accounting statement. We will respond to your request for an accounting within thirty (30) days of receiving the request.

Ø 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. In an emergency situation, we will send you the notice as soon as possible after the emergency (usually, by mail).

EFFECTIVE DATE and DURATION of THIS NOTICE

Ø Effective Date. This Notice is effective on January 1, 2010.

Ø 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 this new notice. If we change this Notice, we will post the new notice in a clear and prominent location where it is reasonable to expect individuals seeking service from us to be able to read the notice, and on our Internet site at www.paladintransport.org. We will not post this notice in our ambulances, as it would be unreasonable to do so, due to space limitations. You also may obtain any new notice by contacting the Privacy Office.

Ø 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 of 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. PRIVACY OFFICE

You may contact the Privacy Officer or the Assistant Privacy Officer at:

PALADIN MEDICAL TRANSPORT, INC.

1201 W. Third Street

Farmville, VA 23901

Telephone: 434-315-5620

Fax: 434-315-5840

E-mail: paladinmedicaltransport@gmail.com