Medical Information Privacy
, Sensitive Information Policy and Program
(To protect your privacy. Audrain Ambulance District has implemented the following policy/program. It details what information will be retained by us.)
The risk to the office, its employees and customers from data loss and identity theft is of significant concern to the office and can only be reduced through the combined efforts of every employee and contractor.
2. Purpose
Define sensitive information
Identify risks that signify potentially fraudulent activity within new or existing covered accounts
This policy and protection program apply to employees, contractors, consultants, temporary workers, and other workers at the office, including all personnel affiliated with third parties.
4. Policy
4.1. Sensitive Information Policy
4.1.1. Definition of Sensitive Information
Sensitive information includes the following items whether stored in electronic or printed format:
4.1.1.1. Personal Information – Sensitive information consists of personal information including, but not limited to:
4.1.1.1.1. Credit Card Information, including any of the following:
4.1.1.1.5. Medical Information for any Employees or Customers, including but not limited to:
4.1.1.2.1. Office, employee, customer, vendor, supplier confidential, proprietary information or trade secrets.
4.1.1.2.2. Proprietary and/or confidential information, among other things, includes: business methods, customer utilization information, retention information, sales information, marketing and other Office strategy, computer codes, screens, forms, information about, or received from, Office’s current, former and prospective customers, sales associates or suppliers or any other non-public information. Proprietary and/or confidential information also includes the name and identity of any customer or vendor and the specifics of any relationship between and among them and the office.
4.1.1.3. Any document marked “Confidential,” “Sensitive,” “Proprietary,” or any document similarly labeled.
4.1.1.4. The office personnel are encouraged to use common sense judgment in securing the office confidential information to the proper extent. If an employee is uncertain of the sensitivity of a particular piece of information, he/she should contact their supervisor/manager.
4.1.2. Hard Copy Distribution
Every employee and contractor performing work for the office will comply with the following policies:
4.1.2.1. File cabinets, desk drawers, overhead cabinets, and any other storage space containing documents with sensitive information will be locked when not in use.
4.1.2.2. Storage rooms containing documents with sensitive information and record retention areas will be locked at the end of each workday.
4.1.2.3. Desks, workstations, work areas, printers and fax machines, and common shared work areas will be cleared of all documents containing sensitive information when not in use.
4.1.2.4. Whiteboards, dry-erase boards, writing tablets, etc. in common shared work areas will be erased, removed, or shredded when not in use.
4.1.2.5. When documents containing sensitive information are discarded they will be placed inside a locked shred bin or immediately shredded using a mechanical cross cut or Department of Defense (DOD) approved shredding device. Locked shred bins are labeled “Confidential paper shredding and recycling”. If you need any assistance in locating one of these bins, please contact a supervisor/manager.
4.1.3. Electronic Distribution
Every employee and contractor performing work for the office will comply with the following policies:
4.1.3.1. Internally, sensitive information may be transmitted using approved office email. All sensitive information must be encrypted when stored in an electronic format.
4.1.3.2. Any sensitive information sent external must be encrypted and password protected and only to approved recipients. Additionally, a statement such at this should be included in the email:
“This message may contain confidential and/or proprietary information, and is intended for the person/entity to whom it was originally addressed. Any use by others is strictly prohibited.”
4.2. Additional Identity Theft Prevention Program
If the office maintains certain covered accounts pursuant to federal legislation, the office may include the additional program details. The Red Flags in 4.2.2 may be tailored to the specific office’s needs.
4.2.1. Covered Accounts
Every new and existing customer account that meets the following criteria is covered by this program
4.2.1.1. Business, personal and household accounts for which there is a reasonably foreseeable risk of identity theft.
4.2.1.2. Business, personal and household accounts for which there is a reasonably foreseeable risk to the safety and/or soundness of the office from identity theft, including financial, operational, compliance, reputation, or litigation risks.
4.2.2. Red Flags
The following ‘Red Flags’ are potential indicators of fraud and any time when a Red Flag, or a situation closely resembling a Red Flag, is apparent, it should be investigated for verification.
4.2.2.1. Alerts, Notifications or Warnings from a Consumer Reporting Agency
4.2.2.1.1. A fraud or active duty alert is included with a consumer report.
4.2.2.1.2. A consumer reporting agency provides a notice of credit freeze in response to a request for a consumer report.
4.2.2.1.3. A consumer reporting agency provides a notice of address discrepancy, as defined in § 334.82(b) of this part.
4.2.2.1.4. A consumer report indicates a pattern of activity that is inconsistent with the history and usual pattern of activity of an applicant or customer, such as:
4.2.2.2. Suspicious Documents
4.2.2.2.1. Documents provided for identification appear to have been altered or forged.
4.2.2.2.2. The photograph or physical description on the identification is not consistent with the appearance of the applicant or customer presenting the identification.
4.2.2.2.3. Other information on the identification is not consistent with information provided by the person opening a new covered account or customer presenting the identification.
4.2.2.2.4. Other information on the identification is not consistent with readily accessible information that is on file with the financial institution or creditor, such as a signature card or a recent check.
4.2.2.2.5. An application appears to have been altered or forged, or gives the appearance of having been destroyed and reassembled.
4.2.2.3. Suspicious Personal Identifying Information
4.2.2.3.1. Personal identifying information provided is inconsistent when compared against external information sources used by the financial institution or creditor. For example:
4.2.2.3.3. Personal identifying information provided is associated with known fraudulent activity as indicated by internal or third-party sources used by the financial institution or creditor. For example:
4.2.2.3.6. The address or telephone number provided is the same as or similar to the account number or telephone number submitted by an unusually large number of other persons opening accounts or other customers.
4.2.2.3.7. The person opening the covered account or the customer fails to provide all required personal identifying information on an application or in response to notification that the application is incomplete.
4.2.2.3.8. Personal identifying information provided is not consistent with personal identifying information that is on file with the financial institution or creditor.
4.2.2.3.9. For financial institutions and creditors that use challenge questions, the person opening the covered account or the customer cannot provide authenticating information beyond that which generally would be available from a wallet or consumer report.
4.2.2.4. Unusual Use of, or Suspicious Activity Related to, the Covered Account
4.2.2.4.1. Shortly following the notice of a change of address for a covered account, the institution or creditor receives a request for new, additional, or replacement cards or a cell phone, or for the addition of authorized users on the account.
4.2.2.4.2. A new revolving credit account is used in a manner commonly associated with known patterns of fraud patterns. For example:
4.2.2.4.5. Mail sent to the customer is returned repeatedly as undeliverable although transactions continue to be conducted in connection with the customer’s covered account.
4.2.2.4.6. The financial institution or creditor is notified that the customer is not receiving paper account statements.
4.2.2.4.7. The financial institution or creditor is notified of unauthorized charges or transactions in connection with a customer’s covered account.
4.2.2.5. Notice from Customers, Victims of Identity Theft, Law Enforcement Authorities, or Other Persons Regarding Possible Identity Theft in Connection with Covered Accounts Held by the Financial Institution or Creditor
4.2.2.5.1. The financial institution or creditor is notified by a customer, a victim of identity theft, a law enforcement authority, or any other person that it has opened a fraudulent account for a person engaged in identity theft.
4.2.3. Responding to Red Flags
Once potentially fraudulent activity is detected, it is essential to act quickly as a rapid appropriate response can protect customers and the office from damages and loss.
4.2.3.1. Once potentially fraudulent activity is detected, gather all related documentation and write a description of the situation. Take this information and present it to the designated authority for determination.
4.2.3.2. The designated program representative will complete additional authentication to determine whether the attempted transaction was fraudulent or authentic.
4.2.3.3. If a transaction is determined to be fraudulent, appropriate actions must be taken immediately. Actions may include:
4.2.4 Periodic Updates to Plan
4.2.4.1. At periodic intervals established in the program, or as required, the program will be re-evaluated to determine whether all aspects of the program are up to date and applicable in the current business environment.
4.2.4.2. Periodic reviews will include an assessment of which accounts are covered by the program.
4.2.4.3. As part of the review, Red Flags may be revised, replaced or eliminated. New Red Flags may also be appropriate.
4.2.4.4. Actions to take in the event that fraudulent activity is discovered may also require revision to reduce damage to the office and its customers.
4.2.5. Program Administration
4.2.5.1. Involvement of Senior Management
4.2.5.1.1. The Identity Theft Prevention Program shall not be operated as an extension to existing fraud prevention programs and its importance warrants the highest level of attention.
4.2.5.1.2. The Identity Theft Prevention Program is the responsibility of the Board of Directors. Approval of the initial plan must be appropriately documented and maintained.
4.2.5.1.3. Operational responsibility of the program can be delegated to a designated employee.
4.2.5.2. Staff Training
4.2.5.2.1. Staff training shall be conducted for all employees, contractors for whom it is reasonably foreseeable that they may come into contact with accounts or Personally Identifiable Information which may constitute a risk to the office or its customers.
4.2.5.2.2. Staff members shall continue to receive training as required as changes to the program are made to ensure maximum effectiveness of the program.
4.2.5.3. Oversight of Service Provider arrangements
4.2.5.3.1. It is the responsibility of the office to ensure that the activities of all Service Providers are conducted in accordance with reasonable policies and procedures designed to detect prevent, and mitigate the risk of identity theft.
4.2.5.3.2. A Service Provider that maintains its own Identity Theft Prevention Program, consistent with the guidance of the Red Flag Rules and validated by appropriate due diligence, may be considered to be meeting these requirements.
4.2.5.3.3. Any specific requirements should be specifically addressed in the appropriate contract arrangements.
5. Roles and Responsibilities
Management will have the responsibility to adopt, implement and enforce this policy and ensure that it is followed by employees and contractors. Additional responsibilities regarding the operation of the Identity Theft Prevention Program may be outlined above or as listed in additional written guidance.
6. Definitions
Board of Directors, in addition to the plain meaning, for companies that do not have a Board of Directors, this term is defined as a designated employee at the senior level of management. Encryption the translation of data into a secret code. Encryption is the most effective way to achieve data security. To read an encrypted file, you must have access to a secret key or password that enables you to decrypt it. Unencrypted data is called plain text. Hard Copy a printout of data stored in a computer. It is considered hard because it exists physically on paper, whereas a soft copy exists only electronically.Service Provider any person or entity that maintains, processes, or otherwise is permitted access to customer information or consumer information through the provision of services directly to the office.
7. Enforcement
Any employee found to have violated this policy may be subject to disciplinary action, up to and including termination of employment.
(To protect your privacy. Audrain Ambulance District has implemented the following policy/program. It details what information will be retained by us.)
- Background
- Purpose
- Scope
- Policy
- Roles and Responsibilities
- Definitions
- Enforcement
The risk to the office, its employees and customers from data loss and identity theft is of significant concern to the office and can only be reduced through the combined efforts of every employee and contractor.
2. Purpose
Define sensitive information
- Describe the physical security of data when it is printed on paper
- Describe the electronic security of data when stored and distributed
Identify risks that signify potentially fraudulent activity within new or existing covered accounts
- Detect risks when they occur in covered accounts
- Respond to risks to determine if fraudulent activity has occurred and act if fraud has been attempted or committed
- Update the program periodically, including reviewing accounts that are covered and identified risks that are part of the program.
This policy and protection program apply to employees, contractors, consultants, temporary workers, and other workers at the office, including all personnel affiliated with third parties.
4. Policy
4.1. Sensitive Information Policy
4.1.1. Definition of Sensitive Information
Sensitive information includes the following items whether stored in electronic or printed format:
4.1.1.1. Personal Information – Sensitive information consists of personal information including, but not limited to:
4.1.1.1.1. Credit Card Information, including any of the following:
- Credit Card Number (in part or whole)
- Credit Card Expiration Date
- Cardholder Name
- Cardholder Address
- Social Security Number
- Social Insurance Number
- Business Identification Number
- Employer Identification Numbers
- Paychecks
- Pay stubs
- Pay rates
4.1.1.1.5. Medical Information for any Employees or Customers, including but not limited to:
- Doctor names and claims
- Insurance claims
- Prescriptions
- Any related personal medical information
- Date of Birth
- Address
- Phone Numbers
- Maiden Name
- Names
- Customer Number
4.1.1.2.1. Office, employee, customer, vendor, supplier confidential, proprietary information or trade secrets.
4.1.1.2.2. Proprietary and/or confidential information, among other things, includes: business methods, customer utilization information, retention information, sales information, marketing and other Office strategy, computer codes, screens, forms, information about, or received from, Office’s current, former and prospective customers, sales associates or suppliers or any other non-public information. Proprietary and/or confidential information also includes the name and identity of any customer or vendor and the specifics of any relationship between and among them and the office.
4.1.1.3. Any document marked “Confidential,” “Sensitive,” “Proprietary,” or any document similarly labeled.
4.1.1.4. The office personnel are encouraged to use common sense judgment in securing the office confidential information to the proper extent. If an employee is uncertain of the sensitivity of a particular piece of information, he/she should contact their supervisor/manager.
4.1.2. Hard Copy Distribution
Every employee and contractor performing work for the office will comply with the following policies:
4.1.2.1. File cabinets, desk drawers, overhead cabinets, and any other storage space containing documents with sensitive information will be locked when not in use.
4.1.2.2. Storage rooms containing documents with sensitive information and record retention areas will be locked at the end of each workday.
4.1.2.3. Desks, workstations, work areas, printers and fax machines, and common shared work areas will be cleared of all documents containing sensitive information when not in use.
4.1.2.4. Whiteboards, dry-erase boards, writing tablets, etc. in common shared work areas will be erased, removed, or shredded when not in use.
4.1.2.5. When documents containing sensitive information are discarded they will be placed inside a locked shred bin or immediately shredded using a mechanical cross cut or Department of Defense (DOD) approved shredding device. Locked shred bins are labeled “Confidential paper shredding and recycling”. If you need any assistance in locating one of these bins, please contact a supervisor/manager.
4.1.3. Electronic Distribution
Every employee and contractor performing work for the office will comply with the following policies:
4.1.3.1. Internally, sensitive information may be transmitted using approved office email. All sensitive information must be encrypted when stored in an electronic format.
4.1.3.2. Any sensitive information sent external must be encrypted and password protected and only to approved recipients. Additionally, a statement such at this should be included in the email:
“This message may contain confidential and/or proprietary information, and is intended for the person/entity to whom it was originally addressed. Any use by others is strictly prohibited.”
4.2. Additional Identity Theft Prevention Program
If the office maintains certain covered accounts pursuant to federal legislation, the office may include the additional program details. The Red Flags in 4.2.2 may be tailored to the specific office’s needs.
4.2.1. Covered Accounts
Every new and existing customer account that meets the following criteria is covered by this program
4.2.1.1. Business, personal and household accounts for which there is a reasonably foreseeable risk of identity theft.
4.2.1.2. Business, personal and household accounts for which there is a reasonably foreseeable risk to the safety and/or soundness of the office from identity theft, including financial, operational, compliance, reputation, or litigation risks.
4.2.2. Red Flags
The following ‘Red Flags’ are potential indicators of fraud and any time when a Red Flag, or a situation closely resembling a Red Flag, is apparent, it should be investigated for verification.
4.2.2.1. Alerts, Notifications or Warnings from a Consumer Reporting Agency
4.2.2.1.1. A fraud or active duty alert is included with a consumer report.
4.2.2.1.2. A consumer reporting agency provides a notice of credit freeze in response to a request for a consumer report.
4.2.2.1.3. A consumer reporting agency provides a notice of address discrepancy, as defined in § 334.82(b) of this part.
4.2.2.1.4. A consumer report indicates a pattern of activity that is inconsistent with the history and usual pattern of activity of an applicant or customer, such as:
- A recent and significant increase in the volume of inquiries
- An unusual number of recently established credit relationships
- A material change in the use of credit, especially with respect to recently established credit relationships
- An account that was closed for cause or identified for abuse of account privileges by a financial institution or creditor
4.2.2.2. Suspicious Documents
4.2.2.2.1. Documents provided for identification appear to have been altered or forged.
4.2.2.2.2. The photograph or physical description on the identification is not consistent with the appearance of the applicant or customer presenting the identification.
4.2.2.2.3. Other information on the identification is not consistent with information provided by the person opening a new covered account or customer presenting the identification.
4.2.2.2.4. Other information on the identification is not consistent with readily accessible information that is on file with the financial institution or creditor, such as a signature card or a recent check.
4.2.2.2.5. An application appears to have been altered or forged, or gives the appearance of having been destroyed and reassembled.
4.2.2.3. Suspicious Personal Identifying Information
4.2.2.3.1. Personal identifying information provided is inconsistent when compared against external information sources used by the financial institution or creditor. For example:
- The address does not match any address in the consumer report
- The Social Security Number (SSN) has not been issued, or is listed on the Social Security Administration’s Death Master File
4.2.2.3.3. Personal identifying information provided is associated with known fraudulent activity as indicated by internal or third-party sources used by the financial institution or creditor. For example:
- The address on an application is the same as the address provided on a fraudulent application
- The address on an application is fictitious, a mail drop, or prison
- The phone number is invalid, or is associated with a pager or answering service
4.2.2.3.6. The address or telephone number provided is the same as or similar to the account number or telephone number submitted by an unusually large number of other persons opening accounts or other customers.
4.2.2.3.7. The person opening the covered account or the customer fails to provide all required personal identifying information on an application or in response to notification that the application is incomplete.
4.2.2.3.8. Personal identifying information provided is not consistent with personal identifying information that is on file with the financial institution or creditor.
4.2.2.3.9. For financial institutions and creditors that use challenge questions, the person opening the covered account or the customer cannot provide authenticating information beyond that which generally would be available from a wallet or consumer report.
4.2.2.4. Unusual Use of, or Suspicious Activity Related to, the Covered Account
4.2.2.4.1. Shortly following the notice of a change of address for a covered account, the institution or creditor receives a request for new, additional, or replacement cards or a cell phone, or for the addition of authorized users on the account.
4.2.2.4.2. A new revolving credit account is used in a manner commonly associated with known patterns of fraud patterns. For example:
- The majority of available credit is used for cash advances or merchandise that is easily convertible to cash (e.g., electronics equipment or jewelry)
- The customer fails to make the first payment or makes an initial payment but no subsequent payments
- Nonpayment when there is no history of late or missed payments; A material increase in the use of available credit
- A material change in purchasing or spending patterns
- A material change in electronic fund transfer patterns in connection with a deposit account
- A material change in telephone call patterns in connection with a cellular phone account
4.2.2.4.5. Mail sent to the customer is returned repeatedly as undeliverable although transactions continue to be conducted in connection with the customer’s covered account.
4.2.2.4.6. The financial institution or creditor is notified that the customer is not receiving paper account statements.
4.2.2.4.7. The financial institution or creditor is notified of unauthorized charges or transactions in connection with a customer’s covered account.
4.2.2.5. Notice from Customers, Victims of Identity Theft, Law Enforcement Authorities, or Other Persons Regarding Possible Identity Theft in Connection with Covered Accounts Held by the Financial Institution or Creditor
4.2.2.5.1. The financial institution or creditor is notified by a customer, a victim of identity theft, a law enforcement authority, or any other person that it has opened a fraudulent account for a person engaged in identity theft.
4.2.3. Responding to Red Flags
Once potentially fraudulent activity is detected, it is essential to act quickly as a rapid appropriate response can protect customers and the office from damages and loss.
4.2.3.1. Once potentially fraudulent activity is detected, gather all related documentation and write a description of the situation. Take this information and present it to the designated authority for determination.
4.2.3.2. The designated program representative will complete additional authentication to determine whether the attempted transaction was fraudulent or authentic.
4.2.3.3. If a transaction is determined to be fraudulent, appropriate actions must be taken immediately. Actions may include:
- Cancel the transaction
- Notify and cooperate with appropriate law enforcement
- Determine extent of liability to office
- Notify actual customer that fraud has been attempted
4.2.4 Periodic Updates to Plan
4.2.4.1. At periodic intervals established in the program, or as required, the program will be re-evaluated to determine whether all aspects of the program are up to date and applicable in the current business environment.
4.2.4.2. Periodic reviews will include an assessment of which accounts are covered by the program.
4.2.4.3. As part of the review, Red Flags may be revised, replaced or eliminated. New Red Flags may also be appropriate.
4.2.4.4. Actions to take in the event that fraudulent activity is discovered may also require revision to reduce damage to the office and its customers.
4.2.5. Program Administration
4.2.5.1. Involvement of Senior Management
4.2.5.1.1. The Identity Theft Prevention Program shall not be operated as an extension to existing fraud prevention programs and its importance warrants the highest level of attention.
4.2.5.1.2. The Identity Theft Prevention Program is the responsibility of the Board of Directors. Approval of the initial plan must be appropriately documented and maintained.
4.2.5.1.3. Operational responsibility of the program can be delegated to a designated employee.
4.2.5.2. Staff Training
4.2.5.2.1. Staff training shall be conducted for all employees, contractors for whom it is reasonably foreseeable that they may come into contact with accounts or Personally Identifiable Information which may constitute a risk to the office or its customers.
4.2.5.2.2. Staff members shall continue to receive training as required as changes to the program are made to ensure maximum effectiveness of the program.
4.2.5.3. Oversight of Service Provider arrangements
4.2.5.3.1. It is the responsibility of the office to ensure that the activities of all Service Providers are conducted in accordance with reasonable policies and procedures designed to detect prevent, and mitigate the risk of identity theft.
4.2.5.3.2. A Service Provider that maintains its own Identity Theft Prevention Program, consistent with the guidance of the Red Flag Rules and validated by appropriate due diligence, may be considered to be meeting these requirements.
4.2.5.3.3. Any specific requirements should be specifically addressed in the appropriate contract arrangements.
5. Roles and Responsibilities
Management will have the responsibility to adopt, implement and enforce this policy and ensure that it is followed by employees and contractors. Additional responsibilities regarding the operation of the Identity Theft Prevention Program may be outlined above or as listed in additional written guidance.
6. Definitions
Board of Directors, in addition to the plain meaning, for companies that do not have a Board of Directors, this term is defined as a designated employee at the senior level of management. Encryption the translation of data into a secret code. Encryption is the most effective way to achieve data security. To read an encrypted file, you must have access to a secret key or password that enables you to decrypt it. Unencrypted data is called plain text. Hard Copy a printout of data stored in a computer. It is considered hard because it exists physically on paper, whereas a soft copy exists only electronically.Service Provider any person or entity that maintains, processes, or otherwise is permitted access to customer information or consumer information through the provision of services directly to the office.
7. Enforcement
Any employee found to have violated this policy may be subject to disciplinary action, up to and including termination of employment.