THIS NOTICE DETAILS HOW YOUR MEDICAL INFORMATION MAY BE USED AND DISCLOSED AND HOW TO GAIN ACCESS TO THAT INFORMATION.

PLEASE REVIEW CAREFULLY.

By law, every Pharmacy is required to maintain the privacy of “Protected Health Information” (“PHI”), in addition to providing the individuals with notice of those legal duties and practices of privacy with respect to PHI. PHI is the information that may identify an individual and relates their past, present, and future health (mental or physical) or condition and associated health care services to them. This “Notice of Privacy Practices” (“Notice”) explains how a pharmacy may use and disclose your PHI to carry out Healthcare operation, Treatment, or Payment and for other predetermined purposes that are permitted or required by law. This Notice also explains the rights of an individual with respect to the PHI about them.

Each Pharmacy is held accountable to abide by the terms of the Notice. We, the Pharmacy, will not disclose or use your PHI without your written authorization, except as stated in this Notice. However, we reserve the right to change our practices along with the Notice and in turn make the Notice effective for all obtained PHI. Upon request, we will make the revised Notice available to all interested parties.

Individual Health Information Rights

With respect to your PHI, you have the following rights:

Upon request, to obtain a paper copy of the Notice. At any point in time, you have the right to request a copy of the Notice, even if you previously agreed to receive an electronic version. Please contact Sherri Moody, Pharmacist, at Powells Bloomfield Pharmacy to acquire a paper copy.

To request guidelines on certain uses and disclosures of your PHI. Additional restrictions may be requested by an individual on the use and disclosure of their PHI by submitting a written request. The Pharmacy is not required to agree with those limitations.

To attain and inspect a copy of PHI. As long as the Pharmacy maintains the PHI, Individuals have the right to access and copy their PHI, which is contained in a designated record set. Prescription and billing information is normally included in a designated record set. Please send a written request to inspect or copy your PHI. Fees may be applied to cover the costs of supplies, copying, and mailing necessary for fulfilling a request. In certain limited cases, requests for copies or inspeciton of PHI may be denied. In such cases, review of the denial may be requested.

To request an amendment of PHI. If an individual feels that their PHI maintained by the Pharmacy is inaccurate in any way, they may request it be amended. An amendment may be requested as long as the Phamacy maintains the PHI. Please submit a written request to request an amendment. Reasoning for the request must be included to support the request. In isolated cases, the request for an amendment may be denied. In such cases, a disagreement with the statement may be filed and may result in a rebuttal to the statement.

To receive an accounting of disclosures of PHI. After April 14th, 2003, individuals have the right to receive an account of their PHI, covering most disclosures above and beyond treatment, health care operations and payment. Disclosures made directly to the individual or those involved with their health care, authorized by the individual or for the purpose of notification, will be excluded. Certain other exceptions, limitations, or restrictions may apply. Please submit a written request for PHI accounting. A specific time period, of not more than six years, must be included. The initial request for an accounting, within a 12 month timeframe, will be provided at no charge. Additional accountings will have associated fees. Individuals requesting an accounting will be notified in advance of the charges and will have the option to modify or cancel their request.

To request communications of PHI by alternative methods or at alternative locations. An individual may request a written response about their medical details or that it be sent to an alternative address. Please submit a written request to receive a confidential PHI communication. Please include how and where to be contacted. All reasonable requests will be accommodated.

All written requests should be made to Sherri Moody, Privacy Officer for Powells Bloomfield Pharmacy.

Examples of the Use and Disclosure of PHI

The following are examples and descriptions of the uses and disclosures of PHI:

The use of PHI for treatment. An example would be the use of pharmacist-obtained information to dispense prescribed medications. Information related to the services provided and medications dispensed would be documented in an individual’s health record.

The use of PHI for payment. An example would be contacting the pharmacy benefit manager or insurer to confirm payment for an individual’s prescription and the amount of the co-payment. The pharmacy bills either the individual or a third-party payer for the prescription medication costs. An individual’s prescription or personal identifying information may be included on or with the bill.

The use of PHI for health care operations. An example would be the use of health record information to monitor the performance of the treatment provided by the pharmacist. This information would be utilized to improve the healthcare and services quality and effectiveness provided.

A pharmacy is likely to disclose or use PHI for the following purposes:

Business associates: Some services provided are the result of contracts with business associates. Such examples include providers of legal services, computer services, and claims transmittal. To insure that these associates can perform duties we’ve contracted with them for and to bill the individual or the third-party payer for services rendered, the pharmacy may disclose PHI about the individual. Business associates are required to appropriately safeguard PHI to protect the individual.

Communication with individuals involved in your care or payment for your care: Using their judgment, pharmacists and other professional health care givers may disclose relevant PHI regarding personal care or payment related to care to those identified by an individual, such as family members, relatives, and friends.

Health-related communications: A pharmacy may contact an individual to provide information about treatment alternatives, health care related benefits or services of interest, or refill reminders.

Food and Drug Administration (FDA): To enable the FDA to recall, repair, or replace products, the pharmacy may disclose to the FDA, or those persons under its jurisdiction, PHI associated with adverse outcomes with respect to foods, drugs, products and product defects, supplements, or post-marketing surveillance information.

Worker’s Compensation: An individual’s PHI may be disclosed by the pharmacy if authorized or if it is necessary to act in accordance with any laws regulating worker’s compensation or similar law-established programs.

Public Health: PHI regarding the prevention and control of disease, injury, and disability may be disclosed to public health or legal authorities as required by law.

Law enforcement: As required by law for law enforcement purposes, a valid subpoena, or another legal process, a pharmacy may disclose an individual’s PHI.

As required by law: A pharmacy may disclose an individual’s PHI when required to do so by law.

Health oversight activities: For any law-authorized activities, the pharmacy may disclose an individual’s PHI to an oversight agency. Such activities include inspections, investigations, and audits deemed necessary for the government and the licensure to monitor government programs, the healthcare system, and compliance with civil rights laws.

Judicial and administrative proceedings: PHI may be disclosed by an administrative or court order if an individual is involved in a lawsuit or dispute. Should someone else involved in the dispute request PHI via a subpoena, lawful process, or discovery request, PHI may be disclosed only if an effort has been made to notify the individual or obtain an order requested to protect the PHI.

A pharmacy is allowed to disclose or use PHI for the following purposes:

Research: Upon approval from an institutional review board that has established protocols ensuring the protection of PHI from a formal review of the research proposal, researchers may request an individual’s PHI.

Coroners, medical examiners, and funeral directors: A pharmacy may release PHI to a medical examiner or coroner for the purpose of, but not limited to, determining the identity of a deceased person or cause of death. PHI may also be disclosed to funeral directors in fulfilling their duties in accordance with applicable laws.

Organ or tissue procurement organization: For the purposes of tissue donation and transplanting , PHI may be disclosed to any organization involved in procurement, banking, or transplantation of organs.

Fundraising: In conjunction with a fundraising endeavor, the Pharmacy may contact an individual.

Correctional institution: PHI may be disclosed to an institution or its agents to protect the health and safety of an individual or other inmates, if said individual becomes or is already an inmate of a correctional institution.

To avert a serious threat to health or safety: In the case of a serious threat to health or injury of an individual or others in general, PHI may be disclosed as a method of prevention.

Military and veterans: PHI may be released about members of the armed forces, as military command authorities require. Similarly, appropriate military authorities may receive PHI about foreign military personnel.

National security and intelligence activities: PHI may be disclosed to federal intelligence agents, counterintelligence, and for law-authorized security activities.

Protective services for the President and others: To conduct a special investigation, or protect the President, foreign Heads of State, or authorized persons, PHI may be disclosed to authorized federal agents.

Victims of abuse, neglect, or domestic violence: If abuse, neglect, or domestic violence is suspected, PHI may be released to the appropriate government authority, such as a protective service or social service agency. PHI will only be disclosed to the extent required by law if the victim agrees with the disclosure, the disclosure is allowed by law, will not be used against the victim, and is deemed necessary by the public agent receiving the report or to avert serious harm to an individual.

Additional PHI Uses and Disclosures

Additional purposes, beyond those previously discussed or as authorized or allowed by law, may cause the pharmacy to request an individual’s written authorization for PHI disclosure or use. Authorization may be revoked at any time. The Pharmacy, after receiving a written revocation, will discontinue disclosure and use of an individual’s PHI beyond actions already completed in association with the original authorization.

To Report a Problem or for Additional Information

Please contact the Privacy Officer for Powells Bloomfield Pharmacy (see information below) with additional questions or for more information about the Pharmacy’s privacy practices. In the case of suspected violation of privacy rights, you have the right to file a complaint with the Secretary of Health and Human Services. Filing a complaint will in no way result in any retaliation efforts.