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SHEPLEY PHARMACY
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 by law to maintain the privacy of Protected Health
Information (“PHI”) and to provide individuals with notice of our legal
duties and privacy practices with respect to PHI. PHI is 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 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 all PHI we maintain.
Upon request, we will provide any revised Notice to you.
Your Health
Information Rights with Respect to 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. Paper copies of the Notice are available at the pharmacy.
You may also obtain a paper copy, by contacting the manager at Shepley
Pharmacy.
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 sending a written request to Shepley Pharmacy, Attn: Manager,
113 1st St. E, Mount Vernon, IA 52314. We are not required to
agree to those restrictions.
Inspect and obtain a copy of
PHI. 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 send a written request to
Shepley Pharmacy, Attn:
Manager, 113 1st St. E, Mount Vernon, IA 52314.
We may charge you a fee for the costs 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 maintain 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 send a written
request to Shepley Pharmacy, Attn: Manager, 113 1st St. E, Mount
Vernon, IA 52314. 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 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 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 Shepley Pharmacy, Attn: Manager, 113 1st St. E, Mount Vernon,
IA 52314. 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.
For instance, you may request that 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 submit a request in
writing to
Shepley Pharmacy, Attn: Manager, 113 1st St. E, Mount Vernon, IA
52314. 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
We will use PHI
for treatment.
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.
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.
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 service 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 disposal of paper containing PHI. 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 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 PHI
about you 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 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 to do so by law.
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 requested PHI.
We are permitted to
use or disclose PHI about you 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 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 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 and 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 activities:
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 official 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.
HIV/AIDS information:
We
will not disclose any HIV/AIDS-related information, except in situations
where the subject of the information has provided us with a written
authorization allowing the release or where we are authorized or required by
state or federal law to make the disclosure.
Product Rebates:
We may disclose PHI about you, to a specific manufacturer, which is
necessary to comply with the requirements relating to product rebates or
similar programs.
Corporate Wellness Programs:
We may disclose PHI about you as approved by you, to your employer, if you
are enrolled in such program.
Patient Prescription Bottles Brought in For Refills:
We may return any prescription bottles brought in by the patient.
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,
by
sending a written request to the Privacy Officer, at CarePro
Health Services, 402 10th Street SE, Suite 100, Cedar Rapids, IA
52403. If you believe your privacy rights have been violated, you can
file a complaint with the Privacy Officer, in writing,
or with the
Secretary of Health and Human Services. There will be no retaliation for
filing a complaint.
Effective Date
This Notice is effective as of 04/14/03.
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