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PHILLIPS PHARMACIES
MAUSTON, FRIENDSHIP, TOMAH
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.
Section A: Uses and
Disclosures of Protected Health Information
Under applicable law, we are
required to protect the privacy of your individual health
information (information we refer to in this notice as
"Protected Health Information"). We are also
required to provide you with this notice regarding our
policies and procedures regarding your Protected Health
Information (referred to as "PHI") and to abide by
the terms of this notice, as it may be updated from time to
time.
We are permitted to make
certain types of uses and disclosures under applicable law
for treatment, payment, and healthcare operations
purposes. For treatment purposes, such uses and
disclosures will take place in providing, coordinating, or
managing healthcare and its related services by one or more
of your providers, such as when your pharmacist consults
with your physician or a specialist regarding your
medications, treatment or condition.
For payment purposes,
such use and disclosure will take place to obtain or provide
reimbursement for providing pharmaceutical care services,
such as when your case is reviewed to ensure
appropriate care was rendered. For reimbursement
purposes, your PHI may be disclosed to one or several
intermediaries employed by your plan sponsor including but
not limited to insurers, pharmacy benefits managers, claims
administrators and computer switching companies.
For healthcare operations
purposes, such use and disclosure will take place in a
number of ways, including for quality assessment and
improvement, provider review and training,
underwriting activities, reviews and compliance activities;
planning, development, management and administration.
Your information could be used, for example, to assist in
the evaluation of the quality of care you were provided.
We may use and disclose your
PHI, without your authorization, when the pharmacy needs to
contact a physician or physician's staff and is permitted or
required to do so without individual written consent or
authorization. We may use and disclose your PHI if we
are contacted by another pharmacy who states they have your
request and consent to transfer pharmacy records to them.
From time to time, we may
employ the services of business associates who may assist us
in one or more tasks and who may use, change or create PHI.
Business associates are required to comply with all the
privacy regulations on your behalf.
We may disclose PHI about you
without your authorization to comply with workers
compensation laws, as required by law enforcement, legal
proceedings, public health requirements, health oversight
activities and as required by law.
Other uses and disclosures
will be made only with your written authorization, and you
may revoke your authorization at any time by notifying us as
described in Section B, except to the extent the
Pharmacy has already taken action in reliance on a
previously signed authorization form.
You may ask us to restrict
uses and disclosures of your PHI to carry out treatment,
payment, or healthcare operations, or to restrict uses and
disclosures to family members, relatives, friends or other
persons identified by you who are involved in your care or
payment for your care. However, we are not required to
agree to your request.
You have the right to request
the following with respect to your PHI: (i) inspection and
copying; (ii) amendment or correction; (iii) an accounting
of the disclosures of this information by us; (We are
not required to account to you for disclosures made for
treatment, payment, operations, disclosures to you,
disclosures to your care givers, for notifications or as
otherwise excluded by law); and (iv) receipt of a paper copy
of this notice upon request. The Pharmacy may require
patients to make requests for access to their PHI in
writing.
In addition, you may request,
and we must accommodate the request, if reasonable, to
receive communications of PHI by alternative means or at
alternative locations. To make this request please
contact us as described in Section B.
The Pharmacy may charge for
supplies, labor and the postage involved in preparing PHI
for your request. If you desire a price quote for this
service you must request one. You have the right to
withdraw your request of the PHI prior to the delivery.
We may use your name to
reference your prescriptions and pharmaceutical care
services. You may be required to sign a signature log
form or to acknowledge receipt of service, to acknowledge
receipt of this notice and the disclosure of PHI as outlined
herein. We may disclose this information to other
persons who ask for you or your prescriptions by name.
You may restrict or prohibit these uses and disclosures by
notifying a pharmacy representative orally or in writing of
your restriction or prohibition. We are not required
to honor those requests. If you request our services,
we are able to provide treatment services to you, even if
you object to signing the acknowledgement of the receipt of
this notice or if we decide not to honor a request
regarding the information is this document while noting your
requests and refusals in our records. In the event of
an emergency or your incapacity, we will do in our
reasonable judgment what is consistent with your known
preference, and what we determine to be in your best
interest. We will inform you of any such uses or
disclosures under such circumstances and give you an
opportunity to object as soon as practicable.
We may disclose to one of
your family members, to a relative, to a close personal
friend, or to any other person identified by you, PHI that
is directly relevant to the person's involvement with your
care or payment related to your care. In addition,
unless you object, we may use or disclose the PHI to
notify, identify or locate a member of your family
your personal representative, another person responsible for
care, or certain disaster relief agencies of your location,
general condition, or death. If you are incapacitated,
there is an emergency, or you object to this use or
disclosure, we will do what in our judgment is in your best
interest regarding such disclosure and will disclose only
the information that is directly relevant to the person's
involvement with your healthcare. We will also use our
judgment and experience regarding your best interest in
allowing people to pick-up filled prescriptions, or similar
forms of PHI.
We reserve the right to
change the terms of this notice and to make new notice
provisions effective for all PHI we maintain. You may
receive a copy of this notice by contacting us as
outlined in Section B or upon the receipt of pharmacy care
services.
If you believe that your
privacy rights have been violated, you may file a complaint
with us at the location described in Section B or to the
Secretary of the Department of Health and Human Services,
Hubert H. Humphrey Building, 200 Independence Ave SW,
Washington, DC 20201. You will not be retaliated
against for filing a complaint.
Section B: Contacting
Us
You may contact us for further information at:
Phillips
Pharmacy
Val Larmer, Privacy Officer
123 E State Street
PO Box 136
Mauston, WI 53948
(608) 847-5949
This notice is effective
April 14, 2003.
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