NOTICE OF PRIVACY PRACTICES FOR PROTECTED HEALTH INFORMATION
Effective Date: September 17, 2013
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.
This pharmacy is covered by the medical information privacy provisions of the Health Insurance Portability and Accountabilty Act of 1996 (generally called “HIPAA”). As a result, we are required to comply with HIPAA and the Regulations in the use and disclosure of health information by which our patients can be individually identified. This health information is referred to as “Protected Health Information, or “PHI” for short. If you have any questions about this notice, please contact the person listed at the end of this notice.
We are required by law to:
- Make sure that your PHI is kept private
- Give you this notice of our legal duties and privacy practices regarding health information about you
- Follow the terms of our notice that is currently in effect
- Inform you of changes to this notice
HOW WE MAY USE OR DISCLOSE YOUR PROTECTED HEALTH INFORMATION:
The following describes the ways we may use and disclose health information that identifies you. We do not need to ask for your specific authorization to do the things listed in this section.
FOR TREATMENT: We may use and disclose PHI for your treatment and to provide you with treatment-related health care services. This may include consulting with other healthcare providers about your healthcare.
FOR PAYMENT OF SERVICES YOU RECEIVE: We may use and disclose Health Information so that we or others may bill and receive payment from you, an insurance company or a third party for the treatment and services you received. For example, we may give your health plan information about you so that they will pay for your treatment.
FOR HEALTHCARE OPERATIONS: We may use and disclose PHI for health care operations purposes. These uses and disclosures are necessary to make sure that all of our patients receive quality care and to operate and manage our office. For example, we may use and disclose information to make sure the care you receive is of the highest quality.
INDIVIDUALS INVOLVED IN YOUR CARE OR PAYEMENT FOR YOUR CARE: When appropriate, we may share PHI with a person who is involved in your medical care of payment for your care, such as your family or a close friends. We also may notify your family about your location or general condition or disclose such information to an entity assisting in a disaster relief effort.
BUSINESS ASSOCIATES: We may disclose Health Information to our business associates that perform functions on our behalf or provide us with services if the information is necessary for such function or services. For examples, we may use another company to perform billing services on our behalf. All of our business associates are obligated to protect the privacy of your information and are not allowed to use or disclose any information other than as specified in our contract.
OTHER USES AND DISCLOSURES FOR SPECIAL SITUATIONS:
The following describes other situations that occur less frequently where we also may use and disclose your PHI without obtaining your specific authorization.
AS REQUIRED BY LAW: We will disclose PHI when required by a law or regular to do so.
TO AVERT A SERIOUS THREAT TO HEALTH AND SAFETY: We may use and disclose PHI when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Disclosures, however, will be made only to someone who may be able to help prevent the treat.
ORGAN AND TISSUE DONATION: If you are an organ donor, we may disclose your PHI to organizations involved in organ, eye and tissue donation and transplantation in the event you are near death or have died.
MILITARY AND VA: If you are a member of the armed forces, we may release Health Information as required by military command authorities. We also may release PHI as required by military command authorities. We also may release PHI to the appropriate foreign military authority if you are a member of a foreign military.
WORKERS’ COMPENSATION PURPOSES: We may release PHI for workers’ compensation or similar programs. These programs provide benefits for work-related injuries or illness.
PUBLIC HEALTH RISKS: We may disclose PHI for public health activities. These activities general include disclosures to prevent or control disease, injury or disability; report births and deaths; report child abuse or neglect; report reactions to medications or problems with products; notify people of recalls of products they may be using; a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or conditional and the appropriate government authority if we believe a patient has been victim of abuse, neglect or domestic violence.
HEALTHCARE OVERSIGHT ACTIVITIES: We may disclose health information to a health oversight agency for activities authorized by law. These oversight activities includeconducting audits, investigations, inspections, and licensure or disciplinary actions, or for other activities that are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.
FOOD AND DRUG ADMINISTRATION: We may disclose your PHI to the Food and Drug Administration (“FDA), so that the FDA can track the quality, safety and effectiveness of FDA-regulated products.
DATA BREACH NOTIFICATION PURPOSES: We may use or disclose your PHI to provide legally required notices of unauthorized access to or disclosure of your health information.
JUDICIAL AND ADMINISTATIVE PROCEEDINGS: We may disclose your PHI in response to a court order or pursuant to some other lawful process.
LAW ENFORCEMENT: We may release PHI if asked by a law enforcement official if the information is: (1) in response to a court order, subpoena, warrant, summons or similar process; (2) limited information to identify or locate a suspect, fugitive, material witness, or missing person; (3) about the victim of a crime even if, under certain very limited circumstances, we are unable to obtain the person’s agreement; (4) about a death caused by suspected criminal conduct; (5)about criminal conduct on our premises; and (6) in an emergency to report a crime, the location of the crime or victims, or the identity, description or location of the person who committed the crime.
CORONERS, MEDICAL EXAMINERS AND FUNERAL DIRECTORS: We may release Health Information to a coroner or medical examiners. This may be necessary, for example, to identify a deceased person or determine the cause of death. We also may release Health Information to funeral directors as necessary for their duties.
NATIONAL SECURITY: We may disclose PHI to authorized federal officials so they may provide protection to the President, other authorized persons, or feigns heads of state or to conduct special investigations.
INMATES AND INDIVIUDALS IN CUSTODY: If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may share your PHI to the correctional institution or law enforcement official. This release would be if necessary: (1)For the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others: or (3) the safety and security of the correctional institution.
PARENTAL ACCESS: Some Maine laws concerning minors restrict, permit or require disclosure of PHI to parents, guardians, and persons acting in a similar legal status. We will act consistently with Maine law and only make disclosures in accordance with these laws.
MEDICAL RESEARCH: We may disclose your PHI for research purposes, such as studying how well a particular treatment worked. All research projects go through an approval process that includes placing protections on the confidentiality of your PHI. In most cases, these protections include obtaining your authorization first.
USES AND DISCLOSURES YOU MAY LIMIT OR ASK NOT TO BE MADE AT ALL:
The following describes situations where you have the opportunity to agree to, or object to, the use and disclosure of your PHI. Even if you give us authorization to use and disclose your PHI in these situations, you always have the right to revoke that authorization.
FAMILY MEMBERS AND OTHERS INVOLVED IN YOUR CARE: Unless you object, we may disclose to a member of your family, a relative, a close friend or any other person you identify, your PHI that directly relates to that person’s involvement in your health care. If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgment.
DISASTER RELIEF: We may disclose your PHI to disaster relief organizations that seek your PHI to coordinate your care, or notify family and friends of your location or condition in a disaster. We will provide you with an opportunity to agree or object to such a disclosure whenever we practically can do so.
USES AND DISCLOSURES THAT REQUIRE YOUR AUTHORIZATION:
The following uses and disclosures of your Protected Health Information will be made only with your written authorizations:
- Uses and disclosures of PHI for marketing purposes; and
- Disclosures that constitute a sale of your PHI.
Other uses and disclosures of Protected Health Information not covered by this Notice or the laws that apply to us will be made only with your written authorization. Certain types of PHI have additional confidentiality protections under state and federal law. Examples include Protected Health Information Regarding HIV/AIDS and information held by dedicated mental health and substance abuse treatment programs. In many of these situations, we must have your written authorization to use or disclose this information. If you do give us authorization, you may revoke it at any time by submitting a written revocation to our Operations Manager and we will no longer disclose PHI under the authorization. But disclosure that we made in reliance on your authorization before your revoked it will not be affected by the revocation.
YOUR RIGHTS REGARDING YOUR PROTECTED HEALTH INFORMATION:
You have the following rights regarding PHI we have about you:
RIGHT TO INSPECT AND COPY: You have a right to inspect and copy PHI that may be used to make decisions about your care or payment for your care. This includes medical and billing records and any other records that we use to make decisions about your health care. To inspect and copy this Health Information, you must make your request, in writing, to Community Pharmacies. We may up to 30 days to make your PHI available to you and we may charge you a reasonable fee to cover the cost of copying and mailing the information. We may deny your request in certain limited circumstances. If we do deny your request, you have the right to have the denial reviewed by a licensed healthcare professional who was not directly involved in the denial of your request, and we will comply with the outcome the review.
RIGHT TO AN ELECTRONIC COPY OF ELECTRONIC MEDICAL RECORDS: If your PHI is maintained in an electronic format (known as an electronic medical record or an electronic health record), you have the right to request that an electronic copy of your record be given to you or transmitted to another individual or entity. We will make every effort to provide access to your PHI in the form or format your request, if it is readily producible in the form or format you request your record will be provided in either our standard electronic format or if you do not want this form or format, a readable hard copy form. We may charge you a reasonable, cost-based fee for the labor associated with transmitting the electronic medical record.
RIGHT TO GET A NOTICE OF A BREACH: You have the right to be notified upon a breach of any of your unsecured Protected Health Information.
RIGHT TO AMEND: If you feel that the PHI we have is incorrect or incomplete, we may ask us to amend that information. You have the right to request an amendment for as long as the information is kept by or for our office. To request an amendment, you must make your request, in writing, to Community Pharmacies to the person identified at the end of this notice.
RIGHT TO AN ACCOUNTING OF DISCLOSURES: You have the right to request a list of certain disclosures we made of PHI for purposes other than treatment, payment and health care operations or for which you provided written authorization. You must make this request in writing to Community Pharmacies. This list will not include disclosures that were made for your treatment, for payment of your healthcare, for our health care operations, disclosures to you or disclosures that were made with your written authorization.
RIGHT TO REQUEST RESTRICTIONS: You have the right to request a restriction or limitation on the PHI we use or disclose for treatment, payment, or health care operations. You also have the right to request a limit on the PHI we disclose to someone involved in your care or the payment for your care, like a family member or friend. For examples, you could ask that we not share information about a particular diagnosis or treatment with your spouse. You must make this request in writing. We are not required to agree to your request unless you as asking us to restrict the use and disclosure of your PHI to a health plan for payment or health care operations purposes and such information you wish to restrict solely pertains to a health care item or service for which you have paid us “out-of-pocket” in full. If we agree, we will comply with your request unless the information is needed to provide you with emergency treatment.
OUT-OF-POCKET PAYMENTS: If you paid out-of-pocket (in other words, you have requested that we not bill your health plan) in full for a specific item or service, you have the right to ask that your PHI with respect to that item or service not be disclosed to a health plan for purposes of payment or health care operations, and we will honor that request.
RIGHT TO REQUEST CONFIDENTIAL COMMUNICATIONS: You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contract you by mail or at work. You must make this request to us in writing. Your request must specific how or where you wish to be contacted. We will accommodate reasonable request.
RIGHT TO OBTAIN A COPY OF THIS NOTICE: You have the right to a paper or electronic copy of this notice at any time. Just ask for a copy from any of our pharmacies, or by contacting the person listed below.
CHANGES TO THIS NOTICE:
We reserve the right to change this notice and make the new notice apply to Health Information we already have as well as any information receive in the future. We will post a copy of our current notice at the pharmacy.
If you believe your privacy rights have been violated, you may file a complaint with our office or with the Secretary of the Department of Health and Human Services. To file a complaint with our office, contact Amelia Arnold. All complaints must be made in writing. You will not be penalized for filing a complaint.
Our Contact Person’s Name:
Amelia Arnold, Operations Manager
Phone: 207-621-0698 ext 228 Fax: 207-622-3264 Email: firstname.lastname@example.org