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representative has the authority to act on the patient's behalf. The use of a driver's <br /> license, social security card, or other form of government-issued identification is <br /> acceptable for this purpose. If it is impossible for the requestor to physically come in to <br /> make the request and verify this information,the HIPAA Compliance Officer shall ask <br /> the requestor to verify the patient's name, date of birth, SSN, address, and telephone <br /> nurnberoverthephoneandasktherequesto[tosubnnitthe "PatientRequestfor <br /> Restriction of Protected Health Information" Form via email, mail or fax. <br /> 4. Under most circumstances, North State Medical Transport is not legally required to <br /> agree to any request to restrict the use and disclosure of PHI, and given the emergent <br /> nature of our operation, North State Medical Transport generally will not agree to a <br /> restriction unless required by law to do so. However, North State Medical Transport is <br /> required to abide by any restrictions that it agrees to. <br /> Granting a Request for Restriction <br /> 1. North State Medical Transport will and must comply with a requested restriction if: (i) <br /> the request concerns the disclosure of PHI to a health plan for purposes of carrying out <br /> payment or healthcare operations; and (ii)the request pertains to a service for which <br /> North State Medical Transport has been paid out-of-pocket in full. In other words, <br /> North3totuK4edioa|Trensportnouytg[aDtpatientytheriQhttopoyforeuervioaout-of- <br /> pocketandabidebyorequestnottosubrnitac|oirntotheinsurerforthotserv|ce <br /> service. <br /> 2. If North State Medical Transport receives a request from a patient or authorized <br /> representative asking North State Medical Transport to refrain from submitting PHI to a <br /> health plan and the HIPAA Compliance Officer determines that North State Medical <br /> Transport has either been paid in full, or that North State Medical Transport has <br /> received reasonable assurances that it will be paid in full for that service,then North <br /> State Medical Transport will grant the request for restriction and not submit a claim to <br /> insurance for that service. Patients must make a new request for all subsequent <br /> services. <br /> ]. If North State Medical Transport agrees to a requested restriction,the HIPAA <br /> Compliance Officer shall inform the patient of that fact in writing, by sending an <br /> "Acceptance of Request for Restriction of Protected Health Information" letter to the <br /> patient. The HIPAA Compliance Officer shall also note on the "Review of Patient <br /> Request for Restriction of Protected Health Information" Form that the request was <br /> accepted and document all pertinent information regarding the request and acceptance <br /> (date, payment received, etc.). <br /> 4. North State Medical Transport may not use or disclose PHI in violation of the agreed <br /> upon restriction. Notwithstanding, if the individual who requested the restriction is in <br /> need of an emergency service, and the restricted PHI is needed to provide the <br /> emergency service,then North State Medical Transport may use the restricted PHI or <br />