 |
||||||||||||
Privacy Policy BALLWEG FAMILY PHARMACY 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. If you have any questions about this Notice, please contact our Privacy Officer. We are legally required to protect the privacy of your health information. We call this information "protected health information." "Protected health information" is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health condition and related health care services. This Notice of Privacy Practices describes how we may use and disclose your protected health information to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. We are required to abide by the terms of this Notice of Privacy Practices. We may change the terms of our Notice of Privacy Practices, at any time. The new Notice of Privacy Practices will be effective for all protected health information that we maintain at that time. Upon your request, we will provide you with any revised Notice of Privacy Practices. You may obtain the revised Notice by accessing our web site www.ballwegfamilypharmacy.com, calling us and requesting that a revised copy be sent to you in the mail. 1. Uses and Disclosures of Protected Health Information Uses and Disclosures of Protected Health Information Your protected health information may be used and disclosed by us and others outside of our pharmacy that are involved in your care and treatment for the purpose of providing health care services to you. Your protected health information may also be used and disclosed to pay your health care bills and to support our operations. Following are examples of the types of uses and disclosures of your protected health care information that we are permitted to make. These examples are not meant to be exhaustive. Treatment: We will use and disclose your protected health information to provide, coordinate, or manage your health care and related services. This includes the coordination or management of your health care with a third party that has already obtained your permission to have access to your protected health information. We will also disclose protected health information to physicians who may be treating you. Payment: We will use and disclose your protected health information, as needed, to send bills and collect payment from you, your health insurance plan or other third parties for your health care services. For example, we may need to give your health insurance plan information about your treatment so they can pay us or reimburse you. We may also use and disclose protected health information for certain activities that your health insurance plan may undertake before it approves or pays for the health care services we provide for you such as; making a determination of eligibility or coverage for insurance benefits, reviewing services provided to you for medical necessity, and undertaking utilization review activities. Health Care Operations: We may use or disclose, as needed, your protected health information in order to support our business activities These activities include, but are not limited to, quality assessment activities, employee review activities, training of students, licensing, risk management activities, marketing activities, and conducting or arranging for other business activities. We will share your protected health information with third parties that perform various activities (e.g., billing) for us. Whenever an arrangement between our office and a third party involves the use or disclosure of your protected health information, we will have a written contract that contains terms that will protect the privacy of your protected health information. We may use or disclose your protected health information to remind you of your prescription upon such time they are ready to be filled. We may do this, for example, by calling you, leaving a message on an answering machine or sending you a letter. We may use or disclose your protected health information, as necessary, to provide you with information about treatment alternatives or other health-related benefits and services that may be of interest to you. We may also use and disclose your protected health information for other marketing activities. For example, your name and address may be used to send you a newsletter about our practice and the services we offer. We may also send you information about products or services that we believe may be beneficial to you. You may contact our Privacy Officer to request that these materials not be sent to you. Uses and Discloses of Protected Health Information Based upon Your Written Authorization Other uses and disclosures of your protected health information will be made only with your written authorization, unless otherwise permitted or required by law as described below. You may revoke this authorization, at any time, in writing, except to the extent that we have taken an action in reliance on the use or disclosure indicated in the authorization. Other Permitted and Required Uses and Disclosures That May Be Made Subject to Your Opportunity to Object When Others Are Involved in Your Health 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 protected health information 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. We may use or disclose protected health information to notify or assist in notifying a family member, personal representative or any other person that is responsible for your care of your location, general condition or death. Finally, we may use or disclose your protected health information to an authorized public or private entity to assist in disaster relief efforts and to coordinate uses and disclosures to family or other individuals involved in your health care. In all of the above cases, only the protected health information that is relevant to your health care will be disclosed. Other Permitted and Required Uses and Disclosures That May Be Made Without Your Authorization or Opportunity to Object We may use or disclose your protected health information in the following situations without your authorization. These situations include: Required By Law: We may use or disclose your protected health information to the extent that the use or disclosure is required by federal, state or local law. The use or disclosure will be limited to the relevant requirements of the law. Public Health: We may disclose your protected health information for public health activities and purposes to a public health authority that is permitted by law to collect or receive the information. The disclosure will be made for the purpose of controlling disease, injury or disability. Communicable Diseases: We may disclose your protected health information, if authorized by law, to a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading the disease or condition. Health Oversight: We may disclose protected health information to health oversight agency for activities authorized by law, such as audits, investigations, and inspections. Oversight agencies seeking this information include government agencies that oversee the health care system, government benefit programs, other government regulatory programs and civil right laws. Abuse or Neglect: We may disclose your protected health information to a public health authority that is authorized by law to receive reports of child abuse or neglect. In addition, we may disclose your protected health information if we believe that you have been a victim of abuse, neglect or domestic violence to the governmental entity or agency authorized to receive such information. Disclosure will be made consistent with the requirements of applicable federal and state laws. Food and Drug Administration: We may disclose your protected health information to a person or company required by the Food and Drug Administration to report adverse events, product defects or problems, biologic product deviations, track products; to enable product recalls; to make repairs or replacements, or to conduct post marketing surveillance, as required. Legal Proceedings: We may disclose protected health information in the course of any judicial or administrative proceeding, in response to a court or administrative order and in certain conditions in response to subpoena, discovery request or other lawful process. Law Enforcement: We may also disclose protected health information, so long as applicable legal requirements are met, for law enforcement purposes. These law enforcement purposes include (1) legal processes and otherwise required by law, (2) limited information requests for identification and location purposes, (3) pertaining to victims of a crime, (4) suspicion that death has occurred as a result of criminal conduct, (5) in the event that a crime occurs on our premises, and (6) medical emergency (not on our premises) and it is likely that a crime has occurred. Coroners and Organ Donation: We may disclose protected health information to a coroner or medical examiner for identification purposes or for determining the cause of death. Protected health information may be used and disclosed for organ, eye or tissue donation purposes. Research: We may disclose your protected health information 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 protected health information. Criminal Activity: Consistent with applicable federal and state laws, we may disclose your protected health information, if we believe that the use or disclosure is necessary to prevent a serious threat to the health or safety of a person or the public. Workers’ Compensation: Your protected health information may be disclosed by us as authorized to comply with workers’ compensation laws and other similar programs established by law. Inmates: If you are an inmate of a correctional facility, we may use or disclose your protected health information to the correctional facility, its agents or law enforcement officials. 2. Your Rights Following is a statement of your rights with respect to your protected health information and a brief description of how you may exercise these rights. RIGHT TO INSPECT AND COPY You have the right to inspect and obtain a copy of your protected health information that is contained in the pharmacy for as long as we maintain the protected health information. If you wish to inspect or obtain a copy of your protected health information, please obtain a form, Request for Access to Records, from the pharmacy and return the completed form to the pharmacy or return to our Privacy Officer. There may be a reasonable cost-based charge for photocopying documents. You will be notified in advance of incurring such charges if any. Depending on the circumstances, a decision to deny access may be reviewable. Please contact our Privacy Officer if you have any questions about access to your medical record. RIGHT TO REQUEST RESTRICTIONS You have the right to request a restriction on our use or disclosure of your protected health information for the purposes of treatment, payment or health care operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or payment for your care. Your request must state the specific restriction requested and to whom you want the restriction to apply. We are NOT required to agree to a restriction that you may request. If we believe it is in your best interest to permit use and disclosure of your protected health information, your protected health information will not be restricted. If we agree to the requested restriction, we may not use or disclose your protected health information in violation of that restriction unless it is needed to provide emergency treatment. You may request a restriction by completing a "Request for Restriction of Uses & Disclosures, from the pharmacy and return the completed form to our Privacy Officer. RIGHT TO REQUEST SPECIFIC CONFIDENTIAL COMMUNICATIONS 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 our Privacy Officer. RIGHT TO AMEND You have the right to request an amendment of the protected health information the pharmacy maintains about you, if you feel that the protected health information 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. If you wish to amend your protected health information files, please obtain a form, Request for Amendment to Protected Health Information, from the pharmacy and return the completed form to the pharmacy or return to our Privacy Officer. RIGHT TO AN ACCOUNTING OF DISCLOSURES You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information. This accounting does NOT apply to disclosures for purposes of treatment, payment or health care operations as described in this Notice of Privacy Practices. It also excludes disclosures we may have made to you, to family members or friends involved in your care, or for notification purposes. The request for this accounting of disclosures must be made in writing to our Privacy Officer. You must request a specific time frame which may not be longer than six years and which may not include dates before October 24, 2005. The right to receive this information is subject to certain exceptions, restrictions and limitations. RIGHT TO A PAPER COPY OF THIS NOTICE You have the right to obtain a paper copy of this Notice of Privacy Practices from us, upon request, even if you have agreed to accept this notice electronically. To obtain a paper copy of this Notice of Privacy Practices, please ask a pharmacy workforce member, or our Privacy Officer. (You may obtain a copy of the current version of our Notice of Privacy Practices at our website, www.ballwegfamilypharmacy.com.) 3. Complaints You may complain to us or the Secretary of Health and Human Services if you believe we have violated your privacy rights. You may file a complaint with us by notifying our Privacy Officer of your complaint. We will not retaliate against you for filing a complaint. PRIVACY OFFICER You may contact our Privacy Officer as follows:
This notice becomes effective on October 24, 2005. Document Version Number: 1 |
||||||||||||