NOTICE OF PRIVACY PRACTICES Effective April 14, 2003 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 private practices and the rights you, the individual, have 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. Uses and disclosures of PHI for Payment: The pharmacy will disclose your PHI to obtain payment or reimbursement form insurers for your health care services. 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 and disclose PHI about you as required and as limited by law. Uses and disclosures 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, 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 law 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 a 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 for research purposes: The pharmacy may use and disclose PHI about you for research purposes with valid waiver of authorization approved by an institutional review board or a privacy 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 and veteran's activities, national security and intelligence, protective services, department of state functions, 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 associates: 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 a 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 the pharmacy. 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. 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. The right to inspect and/or obtain a copy of 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 of your PHI, please obtain a form, Request for Access to Records, from the pharmacy and return the completed form to the pharmacy. 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. If we do deny the request, you will have the right to have the denial reviewed by someone we designate who was not involve in the initial review. You may ask to 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 of PHI, from the pharmacy and return the completed form to the pharmacy. The right to receive and accounting 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 form, Request for Accounting of Disclosures, from the pharmacy and return the completed form to the pharmacy. You should be aware; however, that such an accounting excludes uses and disclosures made for treatment, payment and 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 with to receive a paper copy of this notice, 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 his designee. If you wish to file a complaint with the pharmacy, please contact the Privacy Officer. If you wish to file a complaint with the Secretary, please write to: The U.S. Department of Health and Human Services Office of the Inspector General 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:
Maple Pharmacy
5829 West Maple Road Suite 129
West Bloomfield, MI 48322
Phone: (248) 757-2503
