|
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.
The Pharmacy is required to maintain the privacy of your Protected Health
Information (PHI) and to provide you with a notice of our legal duties and
privacy practices with respect to PHI. PHI is information about you, including
basic demographic information, that may identify you and that relates to your
past, present or future physical or mental health or condition and related
health care services. This Notice of Privacy Practices (Notice) describes how
we may use and disclose PHI about you to carry out treatment, payment or health
care operations and for other specified purposes that are permitted or required
by law. The Notice also describes your rights with respect to PHI about you.
The Pharmacy is required to follow the terms of this Notice. We will not use or
disclose PHI about you without your written authorization, except as described
in this Notice. We reserve the right to change our practices and this Notice
and to make the new Notice effective for PHI we maintain. Upon request, we will
provide a revised Notice to you.
YOUR HEALTH INFORMATION RIGHTS
You have the following rights with respect to PHI about you:
Inspect and Obtain a copy of PHI about you. You may request to inspect
and obtain a copy of Protected Health Information at any time. (PHI) about you.
You have the right to access and copy PHI about you contained in a designated
record set for as long as the Pharmacy maintains the PHI. The designated record
set usually will include prescription and billing records. To inspect or copy
PHI about you, you must complete the Request to Access Protected Health
Information form and give it to a Pharmacy associate for review. If the request
can be granted, then the Pharmacy associate will provide you with a report
detailing the PHI about you contained in our designated record set. The Request
to Access Protected Health Information form is available upon request at the
Pharmacy counter. We may charge you a fee for the cost of copying, mailing, and
supplies that are necessary to fulfill your request. We may deny your request
to inspect and copy in certain limited circumstances. If you are denied access
to PHI about you, you may request that the denial be reviewed.
Request an amendment of PHI. If you feel that PHI we maintained about
you is incomplete or incorrect, you may request that we amend it. You may
request an amendment for as long as we maintain the PHI. To request an
amendment, you must complete the Request to Amend a Record form and give it to
a Pharmacy associate for review. If the request can be granted, then the
Pharmacy associate will amend the appropriate record (s). The Request to Amend
a Record form is available upon request at the Pharmacy counter. In certain
cases, we may deny your request for amendment. If we deny your request or
amendment, you have the right to file a statement of disagreement with the
decision and we may give a rebuttal to your statement.
Receive an accounting of disclosures of PHI. You have the right to
receive an accounting of the disclosures we have made of PHI about you after
April 14, 2003. This accounting includes only those disclosures required to be
accounted for under the federal privacy standards for health information (45
C.F.R. part 164). Those standards do not require accounting for disclosures for
treatment, payment or health care operations purposes, among others. The
accounting will exclude certain disclosures, such as disclosures made directly
to you, disclosures you authorize, disclosures to friends or family members
involved in your care, disclosures made to regulatory or law enforcement
agencies. The right to receive an accounting is subject to certain other
exceptions, restrictions, and limitations. Your request must specify the time
period, but may not be longer than six years. The first accounting you request
within a 12 month period will be provided free of charge, but you may be
charged for the cost of providing additional accountings. We will notify you of
the cost involved and you may choose to withdraw or modify your request at that
time.
Request communications of PHI by alternative means or at alternative locations.
You have the right to request communications by alternative means or at
alternative locations. For instance, you may request the we contact you about
medical matters only in writing or at a different residence or post office box.
To request confidential communication of PHI about you, you must complete the
Request for Confidential Communications form and give it to a Pharmacy
associate for review. If the request can be granted, then the Pharmacy
associate will make the appropriate changes.
Obtain a paper copy of the notice upon request. You may request a copy
of the Notice at any time. Even if you have agreed to receive the Notice
electronically, you are still entitled to a paper copy. To obtain a paper copy,
contact the Privacy Officer of this organization.
Request a restriction on certain uses and disclosures of PHI. You have
the right to request additional restrictions on our use or disclosure of PHI
about you by completing the Request for Restriction form and giving it to a
Pharmacy associate for review. We are not required to agree to the restriction.
If the restriction is possible, then the Pharmacy associate will process the
request. Request for Restriction form is available upon request at the Pharmacy
counter.
We will accommodate all reasonable requests; however in case of emergency
situations, we may contact you by whatever means we deem necessary. The Request
for Confidential Communications form is available upon request at the Pharmacy
counter.
Examples of How We May Use and Disclose PHI
The following are descriptions and examples of ways we use and disclose PHI:
We will use PHI for treatment.Treatment is the provision, coordination
or management of health care and related services. It also includes but is not
limited to consultations and referrals between one or more of your providers.
Example: Information obtained by the pharmacist will be used to dispense
prescription medications to you. We will document in your record information
related to the medications dispensed to you and services provided to you.
We will use PHI for payment. Payment includes, but is not limited to
actions to make coverage determinations and receive payment (including billing,
claims management, subrogation, plan reimbursement, and utilization review and
preauthorizations). Example: We will contact your insurer or Pharmacy Benefit
Manager to determine whether it will pay for your prescription and the amount
of your copayment. We will bill you or a third-party payor for the cost of
prescription medications dispensed to you. The information on or accompanying
the bill may include information that identifies you, as well as the
prescriptions you are taking.
We will use PHI for health care operations. Health care operations
include but are not limited to quality assessment and improvement, reviewing
competence or qualifications of health care professionals, underwriting,
premium rating and other insurance activities relating to creating or renewing
insurance contracts. It also includes disease management, case management,
conducting or arranging for medical review, legal services and auditing
functions including fraud and abuse compliance programs, business planning and
development, business management and general administrative activities.
Example: The Pharmacy may use information in your health record to monitor the
performance of the pharmacists providing treatment to you. This information
will be used in an effort to continually improve the quality and effectiveness
of the health care and services we provide.
We are likely to use or disclose PHI for the following purposes:
Business associates: There are some services provided by us through
contracts with business associates. Examples include Claims Processors or
Administrators, Pharmacy Benefit Managers, etc. When these services are
contracted for, we may disclose PHI about you to our business associate so that
they can perform the job we have asked them to do and bill you or your
third-party payor for services rendered. To protect PHI about you, we require
the business associate to appropriately safeguard the PHI.
Communication with individuals involved in your care or payment for your care:
Health professionals such as pharmacists, using their professional judgment,
may disclose to a family member, other relative, close personal friend or any
person you identify, PHI relevant to that person's involvement in your care or
payment related to your care.
Health-related communications: We may contact you to provide refill
reminders or information about treatment alternatives or other health related
benefits and services that may be of interest to you.
Food and Drug Administration (FDA): We may disclose to the FDA, or
persons under jurisdiction of the FDA, PHI relative to the adverse events with
respect to drugs, foods, supplements, products and product defects, or
post-marketing surveillance information to enable product recalls, repairs, or
replacement.
Workers' compensation: We may disclose PHI about you as authorized by
and as necessary to comply with laws relating to workers' compensation or
similar programs established by law.
Public Health: As required by law, we may disclose PHI about you to
public health or legal authorities charged with preventing or controlling
disease, injury, or disability.
Law Enforcement: We may disclose PHI about you for law enforcement
purposes as required by law or in response to a valid subpoena or other legal
process.
As required by law: We must disclose PHI about you when required by law
to do so.
Health oversight activities: We may disclose PHI about you to an
oversight agency for activities authorized by law. These oversight activities
include audits, investigations, and inspections, as necessary for our licensure
and for the government to monitor the health care system, government programs,
and compliance with civil rights laws.
Judicial and administrative proceedings: If you are involved in a
lawsuit or a dispute, we may disclose PHI about you in response to a court or
administrative order. We may also disclose PHI about you 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 PHI.
In addition, we are permitted to use or disclose PHI for the following purposes:
Research: We may disclose PHI about you to researchers when their
research has been approved by an institutional review board that has reviewed
the research proposal and established protocols to ensure the privacy of your
information.
Coroners, medical examiners, and funeral directors: We may release PHI
about you to a coroner or medical examiner. This may be necessary, for example,
to identify a deceased person or determine the cause of death. We may also
disclose PHI to funeral directors consistent with applicable law to carry out
their duties.
Organ or tissue procurement organizations: Consistent with applicable
law, we may disclose PHI about you to organ procurement organizations or other
entities engaged in the procurement, banking, or transplantation or organs for
the purpose of tissue donation and transplant.
Fundraising: We may contact you as part of a fundraising effort.
Notification: We may use or disclose PHI about you to notify or assist
in notifying a family member, personal representative, or another person
responsible for your care, your location, and your general condition.
Correctional Institution: If you are or become an inmate of a
correctional institution, we may disclose PHI to the institution or its agents
when necessary for your health or the health and safety of others.
To avert a serious threat to health or safety: We may use or disclose
PHI about you when necessary to prevent a serious threat to your health and
safety or the health and safety of the public or another person.
Military and Veterans: If you are a member of the armed forces, we may
release PHI about you as required by military command authorities. We may also
release PHI about foreign military personnel to the appropriate military
authority.
National Security and Intelligence activity: We may release PHI about
you to authorized federal officials for intelligence, counterintelligence, and
other national security activities authorized by law.
Protective Services for the President and others: We may disclose PHI
about you to authorized federal officials so they may provide protection to the
President, other authorized persons or foreign heads of state or conduct
special investigations.
Victims of abuse, neglect, or domestic violence: We may disclose PHI
about you to a government authority, such as a social service or protective
services agency, if we reasonably believe you are a victim of abuse, neglect,
or domestic violence. We will only disclose this type of information to the
extent required by law, if you agree to the disclosure, or if the disclosure is
allowed by law and we believe it is necessary to prevent serious harm to you or
someone else or the law enforcement or public official that is to receive the
report represents that it is necessary and will not be used against you.
OTHER USES AND DISCLOSURES OF PHI
The Pharmacy will obtain your written authorization before using or disclosing
PHI about you for purposes other than those provided for above or as otherwise
permitted or required by law. You may revoke an authorization in writing at any
time. Upon receipt of the written revocation, we will stop using or disclosing
PHI about you, except to the extent that we have already taken action in
reliance on the authorization.
For More Information or to Report a Problem
If you have questions or would like additional information about the Pharmacy's
Privacy Practices, you may contact the Privacy Officer of this organization. If
you believe that your rights have been violated, you can file a complaint with
the Privacy Officer at the above address or with the Secretary of Health and
Human Services. There will be no retaliation for filing a complaint.
|