Notice of Privacy Practices
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 condition and related health care services. This Notice of Privacy Practices (“Notice”) describes how we may use and disclose your PHI to carry out treatment, payment or healthcare operations and for other specified purposes that are permitted or required by law. This Notice also describes your rights with respect to your PHI.
The pharmacy is required to follow the terms of this Notice. We will not disclose your PHI 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.
Individuals may request and be provided an electronic copy of the Notice of Privacy Practices by email. Individuals may also opt out of receiving copies of the Notice of Privacy Practices by email at any time. Please send requests to firstname.lastname@example.org.
Health Information Rights:
You have the following rights with respect to your PHI:
- 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” whose name appears at the end of this notice.
- Request a restriction on certain uses and disclosures of PHI. You have the right to request additional restrictions on our use or disclosure of you PHI by sending a written request to the “Privacy Officer” whose name appears at the end of this notice. We are not required to agree to those restrictions.
- Inspect and obtain a copy of your PHI. You have the right to access and copy your PHI 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 your PHI, you must send a written request to the “Privacy Officer” whose name appears at the end of this notice. We may charge you a fee for the costs of copying, mailing, or other 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 your PHI, you may request that the denial be reviewed.
- Request an amendment of PHI. If you feel that your PHI 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 send a written request to the “Privacy Officer” whose name appears at the end of this notice. You must include a reason that supports your request. In certain cases, we may deny your request for amendment. If we deny your request for amendment, you have the right to file a statement of disagreement with the decision and we 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 your PHI after April 14, 2003 for most purposes other than treatment, payment, or health care operations. 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, and disclosures for notification purposes. The right to receive an accounting is subject to certain other exceptions, restrictions, and limitations. To request an accounting, you must submit a request in writing to the “Privacy Officer” whose name appears at the end of this notice.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 alternative locations. For instance, you may request that we contact you about medical matters only in writing or at different residence or post office box. To request confidential communication of your PHI, you must submit your request in writing to the “Privacy Officer” whose name appears at the end of this notice. Your request must state how or where you would like to be contacted. We will accommodate all reasonable requests.
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.
- We will use PHI for payment.
- We will use PHI for healthcare operations.
We are likely to disclose PHI for the following purposes:
Business Associates: There are some services provided by us through contracts with business associates. Examples include our software system vendor and technology provider. When these services are contracted for, we may disclose your PHI to our business associates 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 your PHI, we require the business associates 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: We may disclose to the FDA, or persons under the jurisdiction of the FDA, PHI relative to adverse events with respect to drugs, foods, supplements, products and product defects, or post marketing surveillance information to enable product recalls, repairs or replacement.
Worker’s Compensation: We may disclose your PHI as authorized by and as necessary to comply with laws relating to worker’s compensation or similar programs established by law.
Public Health: As required by law, we may disclose your PHI to public health or legal authorities charged with preventing or controlling disease, injury, or disability.
Law Enforcement: We may disclose your PHI for law enforcement purposes as required by law or in response to valid subpoena or other legal process.
As required by law: We must disclose your PHI when required to do so by law.
Health oversight activities: We may disclose your PHI 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 your PHI in response to a court or administrative order. We may also disclose your PHI 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 requested PHI.
We are permitted to use or disclose your PHI for the following purposes:
Research: We may disclose your PHI 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 disclose your PHI 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 your PHI to organ procurement organizations or other entities engaged in the procurement, banking, or transplantation of 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 your PHI to notify or assist in notifying a family member, personal representative, or another person responsible for your care, your location, and general condition.
Correctional institution: If you are or becoming an inmate of a correctional institution, we may disclose your 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 and disclose your PHI 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 your PHI as required by military command authorities. We may also release PHI about foreign military personnel to the appropriate military authority.
National security and intelligence activities: We may release your PHI 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 your PHI 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 your PHI to a government authority, such as a social service or protection 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 your PHI for purposes other than those provided for above or as otherwise permitted or required by law. You may revoke this authorization in writing at any time. Upon receipt of the written revocation, we will stop using or disclosing your PHI, 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” whose name appears at the end of this notice at the pharmacy address and telephone number at the top of page 1 of this notice. If you believe your privacy rights have been violated, you can file a complaint with the “Privacy Officer”, whose name appears at the end of this notice, or the Secretary of Health and Human Services. There will be no retaliation for filing a complaint.