Mr. Prescription Inc. / Clark’s RX, LLC
NOTICE
OF PRIVACY PRACTICES
EFFECTIVE APRIL 23, 2008
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.
As part of the federal Health Insurance
Portability and Accountability Act of 1996, known as HIPAA, the
pharmacy has created this Notice of Privacy Practices (Notice). This Notice describes the pharmacy’s privacy
practices and the rights you, the individual, PRShave as they relate to
the privacy of your Protected Health Information (PHI). Your
PHI is information about you, or that could be used to identify you, as
it relates to your past and present physical and mental health care
services. The HIPAA regulations require that the pharmacy protect the
privacy of your PHI that the pharmacy has received or created.
This pharmacy
will abide by the terms presented within this Notice. For
any uses or disclosures that are not listed below, the pharmacy will
obtain a written authorization from you for that use or disclosure,
which you will have the right to revoke at any time, as explained in
more detail below. The
pharmacy reserves the right to change the pharmacy’s privacy practices
and this Notice. Revisions to the
Notice will be posted in the pharmacy and upon your request, provided
to you in a paper format.
HOW THE PHARMACY MAY USE AND
DISCLOSE YOUR PHI
The following
is an accounting of the ways that the pharmacy is permitted, by law, to
use and disclose your PHI.
Uses
and disclosures of PHI for Treatment: We
will use the PHI that we receive from you to fill your prescription and
coordinate or manage your health care. We
may use and disclose your PHI in dispensing prescription medicines and
related products and services, including counseling you and your
caregivers about proper use of your medications. We
may discuss such problems with your other health care professionals,
such as physician or dentist, and through such discussions we may use
your PHI. Finally, we may use or disclose
your PHI to you and your caregivers in our discussions with you and
your caregivers about your treatment.
Uses
and disclosures of PHI for Payment: The pharmacy will disclose your
PHI to obtain payment or reimbursement from insurers for your health
care services. PHI necessary for
collection of payment may include your name, address, social security
number, account number, etc.
Uses
and disclosures of PHI for Health Care Operations: The
pharmacy will use your PHI to conduct quality assessments, improvement
activities, and evaluate the pharmacy workforce.
The following
is an accounting of additional ways in which the pharmacy is permitted
or required to use or disclose PHI about you without your written
authorization.
Uses
and disclosures as required by law: The
pharmacy is required to use or disclose PHI about you as required and
as limited by law.
Uses
and disclosure for Public Health Activities: The
pharmacy may use or disclose PHI about you to a public health authority
that is authorized by law to collect for the purpose of preventing or
controlling disease, injury, or disability.
Uses
and disclosure about victims of abuse, neglect or domestic violence: The
pharmacy may use or disclose PHI about you to a government authority if
it is reasonably believed you are a victim of abuse, neglect or
domestic violence.
Uses
and disclosures for health oversight activities: The pharmacy may
use or disclose PHI about you to a health oversight agency for
oversight activities that it is authorized by lawPRS to conduct.
Disclosures for judicial and
administrative proceedings: The
pharmacy may disclose PHI about you in the course of any judicial or
administrative proceedings, provided that proper documentation is
presented to the pharmacy.
Disclosures
for law enforcement purposes: The pharmacy may disclose PHI about
you to law enforcement officials for authorized purposes.
Uses
and disclosures about the deceased: The pharmacy may disclose PHI
about the deceased, or prior to, and in reasonable anticipation of an
individual’s death, to coroners, medical examiners, and funeral
directors.
Uses
and disclosures for cadaveric organ, eye or tissue donation purposes: The pharmacy may use and disclose PHI for the
purpose of procurement, banking, or transplantation of cadaveric
organs, eyes, or tissues for donation purposes.
Uses and
disclosures at the drive-thru window: The
pharmacy may use or disclose your PHI when counseling. Be
advised that your conversation may be heard by others.
Uses
and disclosures for research purposes: The
pharmacy may use and disclose PHI about you for research purposes with
a valid waiver of authorization from the research board. Otherwise,
the pharmacy will request a signed authorization by the individual for
all other research purposes.
Uses
and disclosures to avert a serious threat to health or safety: The pharmacy may use or disclose PHI about
you, if it believed in good faith, and is consistent with any applicable
law and standards of ethical conduct, to avert a serious threat to
health or safety.
Uses
and disclosures for specialized government functions: The
pharmacy may use or disclose PHI about you for specialized government
functions including; military activities, national security and
intelligence, protective services, and
correctional institutions and law enforcement custodial situations.
Disclosure
for workers’ compensation: The
pharmacy may disclose PHI about you as authorized by and to the extent
necessary to comply with workers’ compensation laws or programs
established by law.
Disclosures
for disaster relief purposes: The
pharmacy may disclose PHI about you as authorized by law to a public or
private entity to assist in disaster relief efforts.
Disclosures
to business assoPRSciates: The pharmacy may
disclose PHI about you to the pharmacy’s business associates for
services that they may provide to or for the pharmacy.
OTHER USES AND DISCLOSURES
The pharmacy
may contact you for the following purposes:
Refill
reminders: The pharmacy may contact
you to remind you of your prescription upon such time they are ready to
be refilled.
Information
about treatment alternatives: The pharmacy may contact you to notify you of
alternative treatments and/or products.
Health
related benefits or services: The
pharmacy may use your PHI to notify you of benefits and services the
pharmacy provides.
Fundraising: If the pharmacy participates in a fundraising
activity, the pharmacy may use demographic PHI to send you fundraising
packet, or the pharmacy may disclose demographic PHI about you to its
business associate or an institutionally related foundation to send you
a fundraising packet. No further
disclosure will be allowed by the business associates or an
institutionally related foundation without your written authorization.
FOR ALL OTHER USES AND
DISCLOSURES
The pharmacy
will obtain a written authorization from you for all other uses and
disclosures of PHI, and the pharmacy will only use or disclose pursuant
to such an authorization. In addition, you
may revoke such an authorization in writing at any time. To revoke a
previously authorized use or disclosure, please contact Mark BonDurant.
YOUR HEALTH INFORMATION RIGHTS
The following
are a list of your rights in respect to your PHI.
Request
restrictions on certain uses and disclosures of your PHI: You have the right to request additional
restrictions of the pharmacy’s uses and disclosures of your PHI;
however, the pharmacy is not required to accommodate a request. If you wish to request additional
restrictions, please obtain the form, Request for
Restriction of Uses & Disclosures, from the pharmacy and return
the completed form to the pharmacy or return to Mark BonDurant.
The
right to have your PHI communicated to you by alternate means or
locations: 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 Mark BonDurant.
The
right to inspect and/or obtain a copy your PHI: You
have the right to request access and/or obtain a copy of your PHI that
is contained in the pharmacy for the duration the pharmacy maintains
PHI about you. If you wish to inspect or
obtain a copy your PHI, please obtain a form, Request for
Access to Records, from the pharmacy and return the completed form
to the pharmacy or return to Mark BonDurant. There
may be a reasonable cost-based charge for photocopying documents. You will be notified in advance of incurring
such charges, if any.
The
right to amend your PHI: You have the
right to request an amendment of the PHI the pharmacy maintains about
you, if you feel that the PHI 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. You may also ask the Secretary, United States
Department of Health and Human Services, or their appropriate designee,
to review such a denial. If you wish to
amend your PHI files, please obtain a form, Request for
Amendment to PHI, from the pharmacy and return the completed form
to the pharmacy or return to Mark BonDurant.
The
right to receive an accouPRSnting of disclosures of your PHI: You
have the right to receive an accounting of certain disclosures of your
PHI made by the pharmacy. If you wish to receive an accounting of
disclosures of your PHI, please obtain a form, Request for
Accounting of Disclosures, from the pharmacy and return the
completed form to the pharmacy or return to the Mark BonDurant. You should be aware, however, that such
an accounting excludes uses and disclosures made for treatment,
payment, or health care operations purposes.
The
right to receive additional copies of the Pharmacy’s Notice of Privacy
Practices: You have the right to
receive additional paper copies of this Notice, upon request, even if
you initially agreed to receive the Notice electronically. If
you wish to receive a paper copy of this request, please ask a pharmacy
workforce member and they will provide you with a copy.
REVISIONS TO THE NOTICE OF
PRIVACY PRACTICES
The pharmacy
reserves the right to change and/or revise this Notice and make the new
revised version applicable to all PHI received prior to its effective
date. The revised Notice will be available, upon request, to all
individuals. The pharmacy will also post
the revised version of the Notice in the pharmacy.
COMPLAINTS
If you believe
your privacy rights have been violated, you may file a complaint with
the pharmacy and/or to the Secretary of HHS, or their designee. If you wish to file a complaint with the
pharmacy, please contact Mark BonDurant. If
you wish to file a complaint with the Secretary, please write to:
The
U.S Department of Health and Human Services
200
Independence Ave, S.W.
Washington,
D.C. 20201
The
pharmacy will not take any adverse action against you as a result of
your filing of a complaint.
CONTACT INFORMATION
If you have any
questions on the pharmacy’s privacy practices or for clarification on
anything contained within the Notice, please contact:
Mr.
Prescription Inc. / Clark’s RX, LLC
Mark
BonDurant
955 Congress Park Drive
Dayton,
OH 45459
937-428-7970
