Streu's Pharmacy,
Inc.
NOTICE OF PRIVACY PRACTICES
THlS NOTICE DESCRIBES HOW MEDICAL
INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED
AND HOW YOU CAN GET ACCESS TO THlS 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'). PHI is information that may identify you and
that relates to your past, present, or future physical or mental health or
condition and related health care services. We are also required to provide you with this notice regarding our policies
and procedures regarding your Protected Health lnformation (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.
In addition, we may contact you to provide refill reminders,
health screenings, wellness events, inoculations, vaccinations or information
about treatment alternatives or other health-related benefits and services that
may be of interest to you. In addition, we may disclose your health Information
to your plan sponsor. In addition, we may contact you for the purpose of fund
raising activities, unless you object.
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 (such as information necessary for our licensure,
for the FDA as related to adverse events/product defects, for coroners and
medical examiners, tissue/organ procurement facilities, correctional
institutions when necessary for your health or safety or the health and safety
of others), 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 (we may
deny an amendment request if the records were not created by our pharmacy, are
not part of our pharmacy's records, or if in our opinion the information
contained in the record is accurate and complete;
(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
or to your care givers, for notifications or as otherwise excluded by law;
(iv) receipt of a paper copy of this notice
upon request
The Pharmacy will require patients
to make requests in writing as described in Section B. The request must specify
the time period of disclosure, which cannot exceed six years. You will be
notified of any cost involved in providing this information and you may choose
to withdraw or modify your request at that time.
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 acknowledgment of the
receipt of this notice or if we decide not to honor a request regarding the
information in 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 and any revised 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
For further information
contact:
Streu's Pharmacy, Inc.
Green Bay, WI
54301
920.437.0206
This
notice is effective 4/1/03