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Sixth Avenue Medical Pharmacy Notice of Privacy Practices I. THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED OR DISCLOSED BY SIXTH AVENUE MEDICAL PHARMACY AND HOW YOU CAN GET ACCESS TO THIS INFORMAION. PLEASE REVIEW IT CAREFULLY. IF YOU HAVE ANY QUESTIONS ABOUT THIS NOTICE, PLEASE CONTACT THE PRIVACY OFFICER. II. WE HAVE A LEGAL DUTY TO SAFEGUARD YOUR PROTECTED HEALTH INFORMATION (PHI). We are legally required to protect the privacy of your health information. We call this information “protected health information” (PHI), and it includes information that can be used to identify you and relates to your past, present, or future physical or mental health or condition, and related health care services. We must provide you with a copy of this notice about our privacy practices, explaining how, when, and why we use and disclose your PHI, with whom that information may be shared and the safeguards we have in place to protect it. This notice also describes your rights to access and amend your PHI. You have the right to approve or refuse the release of specific information by us, except when the release is required or authorized by law or regulation. With some exceptions, we may not use or disclose any more of your PHI than is necessary to accomplish the purpose of the use or disclosure. We are legally required to follow the privacy practices that are described in this notice. We reserve the right to change the terms of this notice and our privacy policies at any time. We will promptly post a revised noticed at the pharmacy main counter. You can also request a copy of this notice from the privacy officer listed below at any time. This notice of privacy practices has been drafted to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Any of the terms not defined in this notice should have the same meaning as they have in HIPAA. III. ACKNOWLEDGMENT OF RECEIPT OF THIS NOTICE. You will be asked to sign an acknowledgment that you received this notice. Our intent is to make you aware of the possible uses and disclosures of your PHI and your privacy rights. The delivery of your health care service will in no way be conditioned upon your signed acknowledgment. If you decline to provide a signed acknowledgment, we will continue to provide your pharmacy services and will use and disclose your PHI for treatment, payment and health care operations pursuant to the terms of this notice.IV. PRIMARY USES AND DISCLOSURES OF PHI. By law, we must disclose your health information to you unless it has been determined by a competent medical authority that it would be harmful to you. We use and disclose health information for many different reasons. For some of these uses or disclosures, we need your prior consent or specific authorization. Below, we describe the different categories of our uses and disclosures and give you some examples of each category. TREATMENTWe will use and disclose your PHI to provide, coordinate and manage your health care and any related services. This includes the coordination or management of your health care with a third party. We may disclose your PHI from time to time with physicians, specialists, other pharmacists or laboratories, which, at the request of your physician or your self becomes involved in your care by providing assistance with your health care, diagnosis or treatment. For example, information obtained by the pharmacist will be used to dispense medication to you. We will document information related to the medication dispensed and services provided you in your record. In emergencies, we will use and disclose your PHI to provide treatment you require. PAYMENTYour PHI will be used as needed to obtain payment for health care service you receive. For example, such use and disclosure will take place to obtain or provide reimbursement for providing pharmaceutical care services. 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 benefit managers, claims administrators and computer switching companies. We may also provide your PHI to our business associates, such as billing companies, claims processing companies, and others that process our pharmacy claims. If you have an account with our pharmacy, we will send you billing statements. These billing statements will include the PHI of any persons on your account. If someone else is responsible for payment of your account, that person will receive your PHI on billing Statements. HEALTH CARE OPERATIONSWe may use or disclose your PHI to support our business functions. These activities include, but are not limited to, quality assessment activities, investigations, oversight or staff performance reviews, training of pharmacy and technician students, communications about a product or service and conducting or arranging for other health care related activities. We may disclose your PHI as necessary to pharmacy and technician students working at our facility. We may call you by name and counsel you at the prescription counter, providing as much privacy as possible. We may use or disclose your PHI, as necessary, to contact you to provide you with additional medication or doctor messages, refill reminders, health screenings, wellness events, inoculations, vaccinations, information about treatment alternatives, other health-related benefits, or for the purpose of fund raising activities. BUSINESS ASSOCIATESWe contract with individuals and entities (Business Associates) to provide various functions on our behalf or to provide certain types of services. To perform the services our Business Associates will receive, create, maintain or disclose PHI, but only after agreeing in writing to appropriately safeguard your PHI. For example, we may disclose your PHI to a Business Associate to administer claims, to provide service support, subrogation, or pharmacy benefit management. Examples of our Business Associates would be third party administrators, accountants, attorneys, and consultants. V. OTHER POSIBLE USES AND DISCLOSURES OF YOUR PHI. The following is a description of other possible ways in which we may use and/or disclose your PHI. REQUIRED BY LAWWe may use or disclose your PHI to the extent required by law. For example, we may disclose your PHI when required by national security laws or public health disclosure laws. LAW ENFORCEMENTUnder certain conditions, we may disclose your PHI to law enforcement officials. For example, some reasons may include, (1) when required by law or some other legal process, (2) when necessary to locate or identify a suspect, fugitive, material witness, or missing persons, or (3) when necessary to provide evidence of a crime that occurred on out premises. PUBLIC HEALTHAs required by law, we may disclose your PHI to public health or legal authorities charged with preventing or controlling disease, injury, or disability. For example, we may use or disclose your PHI when necessary to prevent a serious threat to your health and/or to the health and safety of others. INDIVIDUALS INVOLVED IN YOUR HEALTH CAREUsing our best judgement, we may disclose to a family member, a close personal friend, or any other person identified by you, PHI that is directly relevant to the person’s involvement with your care or payment for your care. We may provide you or any other person identified by you, with an annual Patient Profile Report if you request one for tax purposes. We may release information to parents or guardians as allowed by the law. We may also use or disclose your PHI to an entity assisting in a disaster relief effort so that your family, personal representative, or other person responsible for your care can be notified about your condition, status and location. If you are not present or able to agree to these disclosures of your PHI, we will use our professional judgement to determine whether the disclosure is in your best interest, and will disclose only the information that is directly relevant to the person’s involvement with your healthcare. We will also use our judgement and experience regarding your best interest in allowing people to pick up your prescriptions, or other similar forms of PHI. INMATESWe may disclose PHI if you are or become an inmate of a correctional institution.. We may disclose PHI to the institution or it’s agents when necessary for (1) you health, (2) the safety or others, and/or (3) the safety and security of the correctional institution. WORKERS’ COMPENSATIONWe may disclose your PHI to comply with workers’ compensation laws and other similar programs that provide benefits for work-related injuries or illnesses. SPECIFIC GOVERNMENT FUNCTIONSWe may disclose PHI of military personnel and veterans in certain situations. And we may disclose PHI for national security purposes, such as protecting the President of the United States or conducting intelligence operations. COMPLIANCE REVIEWSWe are required to disclose your PHI to the Secretary of the Department of Health and Human Services when the Secretary in investigating or determining our compliance with HIPAA OTHER USES AND DISCLOSURE OF PHIWe may use your name to reference your prescriptions an pharmaceutical care service. Your may be required to sign a signature log to acknowledge receipt of service, 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. We may provide treatment services to you even if you refuse to sign an acknowledgement that you received this notice, or if we decide not to honor a request regarding the information in this document. In the even of an emergency or your incapacity, we will exercise our professional judgement, and do what is consistent with your best interest. We will inform you of any uses or disclosures, if uses or disclosures would require your signed authorization, under such circumstances and give you an opportunity to object as soon as practicable. VI. YOUR RIGHTS REGARDING YOUR PHI. You may exercise the following rights by submitting a written request to the Sixth Avenue Medical Pharmacy Privacy Officer. Please be aware that Sixth Avenue Medical Pharmacy might deny your request, however, you may seek a review of the denial. RIGHT TO INSPECT AND COPY In most cases, you may inspect and obtain a copy of your PHI contained in a designated record set, for as long as we maintain this information. You must make the request in writing. In certain situations, we may deny your request. If we do, we will tell you, in writing, our reasons for denial and explain your right to have the denial reviewed. We may charge a fee for the costs of coping, mailing or other supplies associated with your request. RIGHT TO REQUEST RESTRICTIONS You have the right to request a restriction on the PHI we use or disclose for treatment, payment or health care operations. We are not required to approve your request, but if we do, we will comply with the restriction unless your information is needed in an emergency situation. Your request must be made in writing to the Sixth Avenue Medical Pharmacy Privacy Officer. In your request you must tell us, (1) what information you want restricted, (2) whether you want to restrict use or disclosure or both, (3) to whom you want the restriction to apply, and (4) an expiration date. RIGHT TO REQUEST CONFIDENTIAL COMMUNICATIONS You may request that we communicate with you using alternative means or at an alternative location. For example, sending information to your work address instead of your home address, or using e-mail rather than regular mail. You must make your request in writing and specify how or where you wish to be contacted. We will accommodate all reasonable requests when possible. We will not ask you the reason for your request. RIGHT TO REQUEST AMENDMENT If you believe the PHI we about you is incorrect or incomplete, you may request an amendment to your PHI as long as we maintain this information. Any request to amend your PHI must be in writing. We may deny a request for an amendment in certain cases. For example, we may deny your request if the information you want to amend is not maintained by us, but by another entity. RIGHT TO AN ACCOUNTING You have the right to an accounting of certain disclosures of your PHI for reasons other than treatment, payment, or healthcare operations. Your request must be in writing, and may not include disclosures made before April 14, 2003. You may request one accounting within a twelve-month period at no charge. We may charge a fee for any additional requests within the same twelve-month period. RIGHT TO OBTAIN A COPY OF THIS NOTICE You have the right to obtain a paper copy of this notice from the Sixth Avenue Medical Pharmacy Privacy Officer. VII. COMPLAINTS. If you believe we have violated your privacy rights, you may file a written complaint with the Sixth Avenue Medical Pharmacy Privacy Officer or the Department of Health and Human Services. Complaints filed directly with the Secretary must, (1) be in writing, (2) contain the name of the entity against which the complaint is lodged, (3) describe the relevant problem, and (4) be filed within 180 days of the time you became or should have become aware of the problem. We will not retaliate against you for filing a complaint with us or with the secretary. VII. CONTACT INFORMATION. You may contact the Sixth Avenue Medical Pharmacy Privacy Officer for further information about the complaint process, for further explanation of your privacy rights, or to exercise any of your rights. Please contact the Sixth Avenue Privacy Officer, Jennifer Brumblay-Daily, W. 508 6th Avenue, Spokane, Washington 99204. You may telephone, fax or e-mail a request for privacy information at: Phone: (509) 455-9345 Email: sampharmacy@qwest.net THIS NOTICE OF
PRIVACY PRACTICES IS
EFFECTIVE
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