NOTICE OF PRIVACY PRACTICE

IMPORTANT: 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.

This notice takes effect on April 1, 2003 and remains in effect until we replace it.

1. OUR PLEDGE REGARDING MEDICAL INFORMATION

As an essential part of our commitment to you, LJH Ambulance maintains the privacy of certain confidential health care information about you, known as Protected Health Information or PHI. We are required by law to protect your health care information and to provide you with the attached Notice of Privacy Practices.

This notice outlines our legal duties and privacy practices respect to your PHI. It not only describes our privacy practices and your legal rights, but lets you know, among other things, how LJH Ambulance is permitted to use and disclose PHI about you, how you can access and copy that information, how you may request amendment of that information, and how you may request restrictions on our use and disclosure of your PHI.

LJH Ambulance is also required to abide by the terms of the version of this Notice currently in effect. In most situations we may use this information as described in this Notice without your permission, but there are some situations where we may use it only after we obtain your written authorization, if we are required by law to do so.

We respect your privacy, and treat all health care information about our patients with care under strict policies of confidentially that all our staff are committed to following at all times.

PLEASE READ THE ATTACHED DETAILED NOTICE. IF YOU HAVE ANY QUESTIONS ABOUT IT, PLEASE CONTACT OUR PRIVACY OFFICER AT

(262) 658-2790.

2. OUR LEGAL DUTY

Law Requires us to:

* Maintain the privacy of protected health information;
* Give you this notice of our legal duties and privacy practices regarding health information about you; and
* Follow the terms of our notice that is currently in effect.

We Have the Right to:

* Change our privacy practices and the terms of this notice at any time, provided that the changes are permitted by law. A revised notice will be available upon written request.
* Make the changes in our privacy practices and the new terms of our notice effective for all medical information that we keep, including information previously created or received before the changes.

3. USE AND DISCLOSURE OF YOUR MEDICAL INFORMATION

The following categories describe ways that we may use and disclose health information that identifies you ("Health Information"). Some of the categories include examples, but every type of use or disclosure of Health Information in a category is not listed. Except for the purposes described below, we will use and disclose Health Information only with your written permission. If you give us permission to use or disclose Health Information for a purpose not discussed in this notice, you may revoke that permission, in writing, at any time by writing to us.

FOR TREATMENT: We may use Health Information to treat you or provide you with health care services. We may disclose Health Information to doctors, nurses, technicians, medical students, or other personnel, including people outside our facility who may be involved in your medical care. We may also share Health Information about you to your other health care providers to assist them in treating you. For example, we may tell your primary physician about the care we provided you or give Health Information to a specialist to provide you with additional services.

FOR PAYMENT: We may use and disclose Health Information so that we or others may bill or receive payment from you, an insurance company or third party for the treatment and services you received. For example, we may give your health plan information about your treatment so that they will pay for such treatment. We also may tell your health plan about a treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment.

FOR HEALTH CARE OPERATIONS: We may use and disclose Health Information for health care operations purposes. These uses and disclosures are necessary to make sure that all of our patients receive quality care and for our operation and management purposes. For example, we may use Health Information to review the treatment and services we provided to ensure that the care you receive is of the highest quality. This might include measuring and improving the quality, evaluating the performance of employees, conducting training programs, and getting accreditation, certificates, licenses and credentials we need to serve you.

FUNDRAISING ACTIVITIES: We may use Health Information to contact you in an effort to raise money. We may disclose Health Information to a related foundation or to our business associate so that they may contact you to raise money for us.

INDIVIDUALS INVOLVED IN YOUR CARE OR PAYMENT FOR YOUR CARE: We may release Health Information to a person who is involved in your medical care or helps pay for your care, such as a family member or friend. We also may notify your family about your location or general condition or disclose such information to an entity assisting in a disaster relief effort.

RESEARCH: Under certain circumstances, we may use and disclose Health Information for research purposes. For example, a research project may involve comparing the health and recovery of all patients who received one medication or treatment to those who received another, for the same condition. Before we use or disclose Health Information for research, though, the project will go through a special approval process. This process evaluates a proposed research project and its use of Health Information to balance the benefits of research with the need for privacy of Health Information. Even without special approval, we may permit researchers to look at records to help them identify patients who may be included in their research project or for other similar purposes, so long as they do not remove or take a copy of any Health Information.

4. SPECIAL CIRCUMSTANCES

In addition to using and disclosing your Health Information for treatment, payment, and health care operations, we may use and disclose Health Information for the following purposes.

AS REQUIRED BY LAW: We will disclose Health Information when required to do so by international, federal, state or local laws.

FACILITY DIRECTORY: Unless you notify us that you object, the following Health Information about you will be placed in our facilities' directories: your name; your location; and your condition described in general terms. We may disclose this information to those who contact use and ask for this information about you by name.

NOTIFICATION: Health Information to notify or help notify: a family member, your personal representative or another person responsible for your care. We will share information about your location, general condition, or death. If you are present, we will get your permission if possible before we share, or give you the opportunity to refuse permission. In case of emergency, and if you are not able to give or refuse permission, we will share only the Health Information that is directly necessary for your health care, according to our professional judgment. We will also use our professional judgment to make decisions in your best interest about allowing someone to pick up medicine, medical supplies, personal belongings, x-ray or medical information for you.

TO AVERT A SERIOUS THREAT TO HEALTH OR SAFETY: We may use and disclose Health Information when necessary to prevent or lessen a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure, however, will be to someone who may be able to help prevent the threat.

BUSINESS ASSOCIATES: We may disclose Health Information to our business associates that perform functions on our behalf or provide us with services if the information is necessary for such functions or services. For example, we may use another company to perform billing services on our behalf. All of our business associates are obligated, under contract with us, to protect the privacy of your information and are not allowed to use or disclose any information other than as specified in our contract.

ORGAN AND TISSUE DONATION: 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 or tissue donation and transplantation.

MILITARY AND VETERANS: If you are a member of the armed forces, we may release Health Information as required by military command authorities. We also may release Health Information to the appropriate foreign military authority if you are a member of a foreign military.

WORKERS COMPENSATION: We may disclose Health Information to comply with laws relating to workers compensation or other similar programs. These programs provide benefits for work-related injuries or illness.

PUBLIC HEALTH RISKS: We may disclose Health Information for public health activities. These activities generally include disclosure to prevent or control disease, injury or disability; report births and deaths; report Elder/child abuse or neglect; report reactions to medications or problems with products; notify people of recalls of products they may be using; track certain products and monitor their use and effectiveness; notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition; and conduct medical surveillance of the office in certain limited circumstances concerning workplace illness or injury. We also may release Health Information to an appropriate government authority if we believe a patient has been the victim of abuse, neglect or domestic violence; however, we will only release this information if you agree or when we are required or authorized by law.

HEALTH OVERSIGHT ACTIVITIES: We may disclose Health Information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.

LAWSUITS AND DISPUTES: If you are involved in a lawsuit or a dispute, we may disclose Health Information in response to a court or administrative order. We also may disclose Health Information in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.

LAW ENFORCEMENT: We may release Health Information if asked by a law enforcement official for the following reasons: (1) in response to a court order, subpoena, warrant, summons or similar process; (2) limited information to identify or locate a suspect, fugitive, material witness, or missing person; (3) about the victim of a crime if, under certain limited circumstances, we are unable to obtain the person's agreement; (4) about a death we believe may be the result of criminal conduct; (5) about criminal conduct on our premises; and (6) 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.

CORONERS, MEDICAL EXAMINERS AND FUNERAL DIRECTORS: We may release Health Information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We also may release Health Information to funeral directors as necessary for their duties.

NATIONAL SECURITY AND INTELLIGENCE ACTIVITIES: We may release Health Information to authorized federal officials for intelligence, counter-intelligence, and other national security activities authorized by law.

PROTECTIVE SERVICES FOR THE PRESIDENT AND OTHERS: We may disclose Health Information to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state or conduct special investigations.

INMATES OR INDIVIDUALS IN CUSTODY: If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release Health Information to the appropriate correctional institution or law enforcement official. This release would be made only if necessary (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) for the safety and security of the correctional institution.

5. YOUR INDIVIDUAL RIGHTS

You have the following rights regarding Health Information we maintain about you:

RIGHT TO INSPECT AND COPY: You have the right to inspect and copy Health Information that may be used to make decisions about your care or payment for your care. To inspect and copy this Health Information, you must make your request, in writing, to our Privacy Officer.

RIGHT TO AMEND: If you feel that Health Information we have 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 us. To request an amendment, you must make your request, in writing, to our Privacy Officer. We may deny your request if we did not create the information you want changed or for certain other reasons. If we deny your request, we will provide you a written explanation. You may respond with a statement of disagreement that will be added to the information you want changed. If we accept your request to change the Health Information, we will make the reasonable efforts to tell others, including people you name, of the change and to include the changes in any future sharing of that information.

RIGHT TO AN ACCOUNTING OF DISCLOSURES: You have the right to request an accounting of certain disclosures of Health Information we made. To request an accounting of disclosures, you must make your request, in writing, to our Privacy Officer.

RIGHT TO REQUEST RESTRICTIONS: You have the right to request a restriction or limitation on the Health Information we use or disclose for treatment, payment, or health care operations. In addition, you have the right to request a limit on the Health Information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend. For example, you could ask that we not share information about your surgery with your spouse. To request a restriction, you must make your request, in writing, to our Privacy Officer. We are not required to agree to your request. If we agree, we will comply with your request unless we need to use the information in certain emergency treatment situations.

RIGHT TO REQUEST CONFIDENTIAL COMMUNICATIONS: You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we contact you only by mail or at work. To request confidential communications, you must make your request, in writing, to our Privacy Officer. Your request must specify how or where you wish to be contacted. We will accommodate reasonable requests.

RIGHT TO A PAPER COPY OF THIS NOTICE: You have the 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 have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice. To obtain a paper copy of this notice, you must make your request, in writing, to our Privacy Officer. To obtain a copy of this notice at our web site, www.ljhambulance.com.

6. QUESTIONS AND COMPLAINTS

If you have any questions about this notice or you believe your privacy rights have been violated, you may file a complaint with us or the Secretary of the Department of Health and Human Services. All complaints must be made in writing. You will not be penalized for filing a complaint. If you have any questions, or if you wish to file a complaint or exercise any rights listed in this Notice, please contact:
LJH Ambulance, Inc.
Attn: Privacy Officer
P.O. Box 1227
Kenosha, WI 53141
(262) 658-2790