THE PRESCRIPTION SHOP
221 SOUTH STATE STREET
JERSEYVILLE, IL 62052
Randy Newberry, R.Ph.
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 Prescription Shop is required to maintain the privacy of your individual health information (information we refer to in this notice as “Protected Health Information” or “PHI”) and to provide you with a notice of our legal duties and privacy practices with respect to PHI. We are permitted to make certain uses and disclosures of your PHI for treatment, payment, and healthcare operations. We will not use or disclose PHI about you without your written authorization, except as described in this Notice.
This Notice is effective as of April 14, 2003.
Your Health Information Rights
You have the following rights with respect to your PHI about you:
· Obtain a paper copy of this Notice upon request. You may request a copy of this Notice at any time. Even if you have agreed to receive this Notice electronically, you are still entitled to a paper copy. To obtain a paper copy, contact the HIPAA Privacy Officer at The Prescription Shop.
· 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 the HIPAA Officer at The Prescription Shop. 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” includes prescription records, other medical information, billing records, enrollment, payment, and claims adjudication. To inspect or copy PHI about you, you must send a written request to the HIPAA Privacy Officer at The Prescription Shop. We may charge you a fee for the costs of copying, mailing, or other supplies that are necessary to grant your request.
· 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. For example, if there is a prescription on your records that you say that you have not received, you may request an amendment. To request an amendment, you must send a written request to the HIPAA Privacy Officer at The Prescription Shop. In addition, you must include a reason that supports your request. In certain cases, after reviewing our records, 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 ask that we give you 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 disclosures we have made directly to you, disclosures to friends or family members involved in your care, and disclosures for notification purposes. To request an accounting, you must submit your request in writing to the HIPAA Privacy Officer at The Prescription Shop. Your request must specify the time period, but may not be longer than six years. 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 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 your request in writing to the HIPAA Privacy Officer at The Prescription Shop. Your request must state how or when 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. 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 may contact your health care provider to clarify a written prescription or to discuss treatment options. We will transfer prescription information to another pharmacy at your request.
We will use PHI for payment. We will contact your insurer, pharmacy benefits manager, or designated discount plan administrator to determine eligibility for payment on your prescription and the amount of your co-payment responsibility. We will bill you or a designated third-party payer for the cost of prescription medications dispensed to you. We may contact the drug manufacturer or their representative to determine qualification and eligibility for any rebate or incentive that would directly or indirectly reduce the cost of your prescription. 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. The Prescription Shop 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 claims processing, data analysis, utilization review, quality assurance, web page hosting, pharmacy computer software programs, billing, benefit management and practice management. 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 payer 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, caregiver or any person you identify, PHI relevant to that person’s involvement in your care or payment related to your care. If there is a specific person or persons who you do not want to have access to your PHI, please notify the Privacy Officer at The Prescription Shop.
Personal communications: We may contact you to provide refill reminders or information about treatment alternatives, wellness events, and other health-related benefits and services that may be of interest to you.
Public Health Activities: We may disclose PHI, without authorization, to public health authorities. Public health authorities include State and local health departments, Food and Drug Administration, Center for Disease Control and Prevention, and Occupational Safety and Health Act. PHI could be disclosed, for example, due to a product recall or outbreak of a disease.
Worker’s compensation: We may disclose PHI about you to the extent authorized by and to the extent necessary to comply with laws relating to worker’s compensation or other similar programs established by law.
As required by law: We may disclose PHI about you to comply with law enforcement and legal 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.
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.
Correctional institution: If you are or become an inmate of a correctional institution, we may disclose to the institution or its agents PHI necessary for your health and the health and safety of others.
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.
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. For more information about this contact the Privacy Officer.
Uses and Disclosures of PHI that Require a Written Authorization
The Pharmacy will obtain your written authorization before using or disclosing PHI about you for purposes other than those provided for above. Circumstances in which a written authorization would be required include marketing, employment determination, pre-enrollment underwriting, and psychotherapy notes. You may revoke this 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.
Authorization for Minors
In most cases, the parent is the personal representative of a minor child (under the age of 18 in Illinois) and can exercise the minor’s rights with respect to PHI. State law will govern aspects of certain information that could be controlled by the minor. For more information, contact the Privacy Officer at The Prescription Shop.
For More Information or to Report a Problem
The purpose of this document is to explain what you may expect with regard to your PHI and to assure you of our intent to provide appropriate administrative, technical, and physical safeguards to protect your privacy. However, it should be understood that in the day-to-day operations of The Prescription Shop some inadvertent disclosure may occur.
If you have questions or would like additional information about the Pharmacy’s privacy practices, you may contact our Privacy Officer, Lynn Crammond R.Ph., at The Prescription Shop, 221 South State Street, Jerseyville, IL 62052. (618-498-2323). If you believe your privacy rights have been violated, you can file a complaint with our Privacy Officer or with the Secretary of Health and Human Services, Hubert H. Humphrey Building, 200 Independence Avenue SW, Washington, DC 20201. There will be no retaliation for filing a complaint.