NOTICE OF PRIVACY PRACTICES
EFFECTIVE APRIL 23, 2008
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.
As part of the federal Health Insurance Portability and
Accountability Act of 1996, known as HIPAA, the pharmacy has created
this Notice of Privacy Practices (Notice). This Notice describes the
pharmacy’s privacy practices and the rights you, the individual, have
as they relate to the privacy of your Protected Health Information
(PHI). Your PHI is information about you, or that could be used to
identify you, as it relates to your past and present physical and mental
health care services. The HIPAA regulations require that the pharmacy
protect the privacy of your PHI that the pharmacy has received or
created.
This pharmacy will abide by the terms presented within this
Notice. For any uses or disclosures that are not listed below, the
pharmacy will obtain a written authorization from you for that use or
disclosure, which you will have the right to revoke at any time, as
explained in more detail below. The pharmacy reserves the right
to change the pharmacy’s privacy practices and this Notice.
Revisions to the Notice will be posted in the pharmacy and upon your
request, provided to you in a paper format.
HOW THE PHARMACY MAY USE AND DISCLOSE YOUR PHI
The following is an accounting of the ways that the pharmacy is
permitted, by law, to use and disclose your PHI.
- Uses and disclosures of PHI for Treatment: We will
use the PHI that we receive from you to fill your prescription and
coordinate or manage your health care. We may use and disclose your PHI
in dispensing prescription medicines and related products and services,
including counseling you and your caregivers about proper use of your
medications. We may discuss such problems with your other health care
professionals, such as physician or dentist, and through such
discussions we may use your PHI. Finally, we may use or disclose your
PHI to you and your caregivers in our discussions with you and your
caregivers about your treatment.
- Uses and disclosures of PHI for Payment: The
pharmacy will disclose your PHI to obtain payment or reimbursement from
insurers for your health care services. PHI necessary for collection of
payment may include your name, address, social security number, account
number, etc.
- Uses and disclosures of PHI for Health Care Operations: The
pharmacy will use your PHI to conduct quality assessments, improvement
activities, and evaluate the pharmacy workforce.
The following is an accounting of additional ways in which the
pharmacy is permitted or required to use or disclose PHI about you
without your written authorization.
- Uses and disclosures as required by law: The
pharmacy is required to use or disclose PHI about you as required and as
limited by law.
- Uses and disclosure for Public Health Activities:
The pharmacy may use or disclose PHI about you to a public health
authority that is authorized by law to collect for the purpose of
preventing or controlling disease, injury, or disability.
- Uses and disclosure about victims of abuse, neglect or
domestic violence: The pharmacy may use or disclose PHI about
you to a government authority if it is reasonably believed you are a
victim of abuse, neglect or domestic violence.
- Uses and disclosures for health oversight activities:
The pharmacy may use or disclose PHI about you to a health oversight
agency for oversight activities that it is authorized by law to
conduct.
- Disclosures for judicial and administrative proceedings: The
pharmacy may disclose PHI about you in the course of any judicial or
administrative proceedings, provided that proper documentation is
presented to the pharmacy.
- Disclosures for law enforcement purposes: The
pharmacy may disclose PHI about you to law enforcement officials for
authorized purposes.
- Uses and disclosures about the deceased: The
pharmacy may disclose PHI about the deceased, or prior to, and in
reasonable anticipation of an individual’s death, to coroners, medical
examiners, and funeral directors.
- Uses and disclosures for cadaveric organ, eye or tissue
donation purposes: The pharmacy may use and disclose PHI for
the purpose of procurement, banking, or transplantation of cadaveric
organs, eyes, or tissues for donation purposes.
- Uses and disclosures at the drive-thru window:
The
pharmacy may use or disclose your PHI when counseling. Be advised that
your conversation may be heard by others.
- Uses and disclosures for research purposes: The
pharmacy may use and disclose PHI about you for research purposes with a
valid waiver of authorization from the research board. Otherwise, the
pharmacy will request a signed authorization by the individual for all
other research purposes.
- Uses and disclosures to avert a serious threat to health or
safety: The pharmacy may use or disclose PHI about you, if it
believed in good faith, and is consistent with any applicable law and
standards of ethical conduct, to avert a serious threat to health or
safety.
- Uses and disclosures for specialized government functions: The
pharmacy may use or disclose PHI about you for specialized government
functions including; military activities, national security and
intelligence, protective services, and correctional institutions and
law enforcement custodial situations.
- Disclosure for workers’ compensation: The pharmacy
may disclose PHI about you as authorized by and to the extent necessary
to comply with workers’ compensation laws or programs established by
law.
- Disclosures for disaster relief purposes: The
pharmacy may disclose PHI about you as authorized by law to a public or
private entity to assist in disaster relief efforts.
- Disclosures to business associates:
The pharmacy may disclose PHI about you to the pharmacy’s business
associates for services that they may provide to or for the pharmacy.
OTHER USES AND DISCLOSURES
The pharmacy may contact you for the following purposes:
- Refill reminders: The pharmacy may contact you to
remind you of your prescription upon such time they are ready to be
refilled.
- Information about treatment alternatives: The pharmacy may contact
you to notify you of alternative treatments and/or products.
- Health related benefits or services: The pharmacy
may use your PHI to notify you of benefits and services the pharmacy
provides.
- Fundraising: If the pharmacy participates in a
fundraising activity, the pharmacy may use demographic PHI to send you
fundraising packet, or the pharmacy may disclose demographic PHI about
you to its business associate or an institutionally related foundation
to send you a fundraising packet. No further disclosure will be allowed
by the business associates or an institutionally related foundation
without your written authorization.
FOR ALL OTHER USES AND DISCLOSURES
The pharmacy will obtain a written authorization from you for all
other uses and disclosures of PHI, and the pharmacy will only use or
disclose pursuant to such an authorization. In addition, you may revoke
such an authorization in writing at any time. To revoke a previously
authorized use or disclosure, please contact Mark BonDurant.
YOUR HEALTH INFORMATION RIGHTS
The following are a list of your rights in respect to your PHI.
- Request restrictions on certain uses and disclosures of your
PHI: You have the right to request additional restrictions of
the pharmacy’s uses and disclosures of your PHI; however, the pharmacy
is not required to accommodate a request. If you wish to request
additional restrictions, please obtain the form, Request for
Restriction of Uses & Disclosures, from the pharmacy and return the
completed form to the pharmacy or return to Mark BonDurant.
- The right to have your PHI communicated to you by alternate
means or locations: You have the right to request that the
pharmacy communicate confidentially with you using an address or phone
number other than your residence. However, state and federal laws
require the pharmacy to have an accurate address and home phone number
in case of emergencies. The pharmacy will consider all reasonable
requests. If you wish to request a change in your communicating address
and/or phone number, please obtain a form, Request for Alternative
Arrangements for Confidential Communication, from the pharmacy and
return the completed form to the pharmacy or return to Mark BonDurant.
- The right to inspect and/or obtain a copy your PHI: You
have the right to request access and/or obtain a copy of your PHI that
is contained in the pharmacy for the duration the pharmacy maintains PHI
about you. If you wish to inspect or obtain a copy your PHI, please
obtain a form, Request for Access to Records, from the pharmacy
and return the completed form to the pharmacy or return to Mark
BonDurant. There may be a reasonable cost-based charge for photocopying
documents. You will be notified in advance of incurring such charges,
if any.
- The right to amend your PHI: You have the right to
request an amendment of the PHI the pharmacy maintains about you, if you
feel that the PHI the pharmacy has maintained about you is incorrect or
otherwise incomplete. Under certain circumstances we may deny your
request for amendment. If we do deny the request, you will have the
right to have the denial reviewed by someone we designate who was not
involved in the initial review. You may also ask the Secretary, United
States Department of Health and Human Services, or their appropriate
designee, to review such a denial. If you wish to amend your PHI files,
please obtain a form, Request for Amendment to PHI, from the
pharmacy and return the completed form to the pharmacy or return to Mark
BonDurant.
- The right to receive an accounting of
disclosures of your PHI: You have the right to receive an
accounting of certain disclosures of your PHI made by the pharmacy. If
you wish to receive an accounting of disclosures of your PHI, please
obtain a form, Request for Accounting of Disclosures, from the
pharmacy and return the completed form to the pharmacy or return to the
Mark BonDurant. You should be aware, however, that such an accounting
excludes uses and disclosures made for treatment, payment, or health
care operations purposes.
- The right to receive additional copies of the Pharmacy’s
Notice of Privacy Practices: You have the right to receive
additional paper copies of this Notice, upon request, even if you
initially agreed to receive the Notice electronically. If you wish to
receive a paper copy of this request, please ask a pharmacy workforce
member and they will provide you with a copy.
REVISIONS TO THE NOTICE OF PRIVACY PRACTICES
The pharmacy reserves the right to change and/or revise this Notice
and make the new revised version applicable to all PHI received prior to
its effective date. The revised Notice will be available, upon request,
to all individuals. The pharmacy will also post the revised version of
the Notice in the pharmacy.
COMPLAINTS
If you believe your privacy rights have been violated, you may file a
complaint with the pharmacy and/or to the Secretary of HHS, or their
designee. If you wish to file a complaint with the pharmacy, please
contact Mark BonDurant. If you wish to file a complaint with the
Secretary, please write to:
The U.S Department of Health and Human Services
200 Independence Ave, S.W.
Washington, D.C. 20201
The pharmacy will not take any adverse action against
you as a result of your filing of a complaint.
CONTACT INFORMATION
If you have any questions on the pharmacy’s privacy practices or for
clarification on anything contained within the Notice, please contact:
Mr. Prescription Inc. / Clark’s RX, LLC
Mark BonDurant
955 Congress Park Drive
Dayton, OH 45459
937-428-7970