NOTICE OF PRIVACY PRACTICES
EFFECTIVE February 20, 2009
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.
This Notice of Privacy Practices is provided to you as a requirement of the Health Insurance Portability and Accountability Act (HIPAA).
We are strongly committed to protecting your medical information, also known as “Identifiable Health Information”. We create a medical record about your care because we need the record to provide you with appropriate treatment and to comply with various legal requirements. We transmit some medical information about your care in order to obtain payment for the services you receive, and we use certain information in our day-to-day operations. This Notice will let you know about the various ways we use and disclose your Protected Health Information. This Notice describes your rights and our obligations with respect to the use or disclosure of your Protected Health Information.
To summarize, this notice provides you with the following important information:
- How we may use and disclose your identifiable health information
- Your privacy rights in your identifiable health information
- Our obligations concerning the use and disclosure of your identifiable health information
We reserve the right to change this Notice. Its effective date is at the top of the first page and at the bottom of the last page. We reserve the right to make the revised Notice effective for Protected Health Information we already have about you, as well as any Protected Health Information we create or receive in the future. You may obtain another Notice of Privacy Practices by asking your practitioner for a copy at your next appointment, sending a written request for a copy to Tomlinson Pharmacy’s Privacy Officer at the address listed below, or sending a request for a copy via e-mail to Wendell@tomlinsonrx.com.
IF YOU HAVE QUESTIONS ABOUT THIS NOTICE. PLEASE CONTACT:
Comoliance Officer. Wendell Smith c/o Tomlinson Pharmacy 108 Rowe St Dublin, GA 31021 or call: 478-272-7722
HOW WE MAY USE OR DISCLOSE YOUR PROTECTED HEALTH INFORMATION
The following categories describe the different types of uses and disclosures of your Protected Health Information that we are permitted or required to make. We have also provided some examples of the types of uses and disclosures that fall within a category. However, not every use or disclosure in a category will be listed.
Treatment We will use and disclose your Protected Health Information to provide, coordinate, or manage your health care and any related treatment. This includes the coordination or management of your health care with a third party. For example, we would disclose your Protected Health Information, as necessary, to the physician that referred you to us. We will also disclose Protected Health Information to other health care providers who may be treating you.
Payment We may use and disclose your Protected Health Information in order to bill and obtain payment for health care services provided to you. This may include certain activities that your health insurance plan may undertake before it approves or pays for the health care services we recommend for you, such as: making a determination of eligibility or coverage for insurance benefits, reviewing services provided to you for medical necessity, and undertaking utilization review activities. We may also tell your health plan about an orthotic or prosthetic device you are going to receive to obtain prior approval or to determine whether your plan will cover the device.
Health Care Operations We may use or disclose your Protected health Information for our business operations. These operations include, but are not limited to, quality assessment activities, development of clinical guidelines, reviewing the qualifications and performance of practitioners and other health care professionals, training activities, legal services and auditing functions, business planning and development and business management and general administrative activities of our facilities. We may share your Protected Health Information with third party “business associates” that perform various activities (e.g., collections, transcription services) for our facilities. Whenever an arrangement between our facility and our business associate involves the use or disclosure of your Protected Health Information, we will have a written contract that contains terms that will protect the privacy of your Protected Health Information.
Treatment Alternatives We may use or disclose your Protected Health Information to provide you with information about treatment alternatives or other health-related products and services that may be of interest to you.
Appointment Reminders We may use or disclose your Protected Health Information to contact you to remind you of your appointment.
Sale of Practice If we decide to sell this practice or merge or combine with another practice, we may share your Protected Health Information with prospective buyers or new owners.
Other Permitted or Required Uses and Disclosures Without Written Authorization
Others Involved in Your Health Care Unless you object, or in the event that you are not present or are incapacitated or in an emergency, we may disclose to a member of your family, a relative, a close friend, or any other person that you identify, your Protected Health Information as it directly relates to that person’s involvement in your Health Care, or payment for such care. Additionally, we may use or disclose Protected Health Information to notify or assist in notifying your family member, your personal representative, or any other person responsible for your care, of your general condition, status and location. Finally, we may also use or disclose your Protected Health Information to an entity assisting in disaster relief efforts so that your family member, your personal representative or other person responsible for your care can be notified about your general condition, status and location.
Required By Law We may use or disclose your Protected Health Information to the extent that the use or disclosure is required by Federal, State or local law.
Public Health We may disclose your Protected Health Information for public health activities to public health authorities who are legally authorized to receive such information. The activities include, but are not limited to: I,) Preventing or controlling disease, injury or disability; 2). Reporting vital events; 3), Reporting child abuse or neglect; 4), Notifying a person regarding exposure to or a potential risk for spreading or contracting a communicable disease or condition; 5) Reporting problems with products; 6). Notifying individuals if a product or device they may be using has been recalled; 7). Notifying your employer under limited circumstances related to workplace injury or illness or medical surveillance.
Health Oversight We may disclose Protected Health Information to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections; licensure and disciplinary actions; and civil, administrative and criminal proceedings or actions. Oversight agencies seeking this information include government agencies that oversee the health care system, government benefit programs, other government regulatory programs and compliance with the civil rights laws.
Abuse or Neglect We may disclose your Protected Health Information to a public health authority that is authorized by law to receive reports of child abuse or neglect. In addition, if we believe that you have been a victim of abuse, neglect or domestic violence, we may disclose your Protected Health Information to a government entity or agency authorized by law to receive reports of abuse, neglect or domestic violence, including a social service or protective services agency. We will only make this disclosure if you agree or when required or authorized by law.
Food and Drug Administration We may disclose your Protected Health Information to a person or company required by the Food and Drug Administration to report adverse events, product defects or problems or biologic product deviations; to track products; to enable product recalls, repairs or replacements; or to conduct post marketing surveillance, as required.
Legal Proceedings We may disclose Protected Health Information about you in response to an order by a court or administrative tribunal. We may also disclose Protected Health Information about you in response to a subpoena, discovery request or other lawful process by a party to a judicial or administrative proceeding, but only if efforts have been made to notify you about the subpoena, discovery request or lawful process, or to obtain an order from the court or administrative tribunal protecting the information requested.
Law Enforcement We may disclose your Protected Health Information in response to a court order, a court-ordered subpoena, warrant or summons. or similar process authorized by law. Also, in response to a request form a law enforcement official, we may disclose Protected Health Information for the purpose of identil)’ing or locating a suspect, fugitive, material witness or missing person; or pertaining to a known or suspected victim of a crime. Finally, we may disclose Protected Health Information to a law enforcement official: (I) to report a death that we suspect may be the result of criminal conduct; (2) to report criminal conduct on our premises; or (3) in the event of a medical emergency (not on our premises), to report a crime, the location of the crime or victims, or the identity, description or location of the person who committed the crime.
Serious Threats to Health or Safety Our organization may use and disclose your identifiable health information when necessary to reduce or prevent a serious threat to your health and safety or the health and safety of another individual or the public. Under these circumstances, we will only make disclosures to a person or organization able to help prevent the threat.
Research Under certain circumstances, we may disclose your Protected Health Information if we believe that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. Under certain circumstances, we may also disclose Protected Health Information if it is necessary for law enforcement authorities to identify or apprehend an individual.
Military Activity and National Security If you are a member of the armed forces, we may release Protected Health Information about you as required by military command authorities. We may also release Protected Health Information about foreign military personnel to the appropriate foreign authority. Finally, we may release Protected Health Information about you to authorized federal officials so that they may: (1) conduct intelligence, counter-intelligence, and other national security activities authorized by law; or (2) provide protection to the President, other authorized persons or foreign heads of state, or conduct special investigations.
Workers’ Compensation We may disclose your Protected Health Information as authorized to comply with workers’ compensation laws and other similar legally established programs that provide benefits for work-related illnesses and injuries.
Inmates If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release Protected Health Information about you to the correctional institution or law enforcement official if necessary: (1) for provision of health care to you; (2) to protect your healthy and safety or the health and safety of others; (3) for law enforcement on the premises of the correctional institution; or (4) for the administration and maintenance of the safety and security of the correctional institution.
Parental Access Some state laws concerning minors permit or require disclosure of Protected Health Information to parents, guardians, and persons acting in a similar legal status. We will comply with the applicable law of the state where the treatment is
YOUR RIGHTS REGARDING YOUR PROTECTED HEALTH INFORMATION
Following is a statement of your rights with respect to your Protected Health Information and a brief description of how you may exercise these rights.
Confidential Communications. You have the right to request that our organization communicate with you about your health and related issues in a particular manner or at a certain location. For example, you may ask that we contact you at home rather than work. In order to request a type of confidential communication, you must make a written request to Compliance Officer, Wendell Smith c/o Tomlinson Pharmacy 108 Rowe St Dublin, GA 31021 or phone 478-272-7722.
You Have the Right to Inspect and Copy. You may inspect and obtain a copy of your Protected Health Information contained in your medical and billing records and any other records that Tomlinson Pharmacy uses for making decisions about you, for as long as we maintain the Protected Health Information. You do not need to give a reason for your request. To inspect and copy your medical information, you must submit a written request to the Compliance Officer at the office(s) where we have provided you with health care services, or to the Tomlinson Pharmacy Privacy Officer at the address listed below. If you request a copy of your information, we may charge you a fee for the costs of copying, mailing or other costs incurred by us in complying with your request.
Right to Request Restrictions. You may ask us not to use or disclose any part of your Protected Health Information for the purposes of treatment, payment or health care operations. You may also request that any part of your Protected Health Information not be disclosed to family members, relatives, friends or other persons who may be involved in your care, or for notification or disaster relief efforts, as described in this Notice. Your request must state the specific restriction requested and to whom you want the restriction to apply. We are not required to agree to your request and may deny request in limited situations. However, if we do agree, we are bound by our agreement except when otherwise required by law, in emergencies, or when the information is necessary to treat you. In order to request a restriction in our use of disclosure of your identifiable health information, you must make your request in writing to Compliance Officer, at Tomlinson Pharmacy, 108 Rowe St. Dublin, GA 31021 or call 478-272-7722. Your request must describe in a clear and concise fashion: 1. the information your wish restricted; 2. whether you are requesting to limit our practice’s use, disclosure or both; and 3. to whom you want the limits to apply.
Amendment. You may ask us to amend your health information if you believe it is incorrect or incomplete, and request an amendment for as long as the information is kept by or for our organization. To request an amendment, your request must be made in writing. Submit to Compliance Officer for Tomlinson Pharmacy at the address above. You must provide us with a reason that supports your request for amendment. We may deny your request if you fail to submit this information in writing. We may also deny your request if you ask us to amend information that is: a. accurate and complete; b. not part of the identifiable health information kept by or for the company; c. not part of the identifiable health information which you would be permitted to inspect and copy; d. not created by our company.
Accounting Disclosures. All of our patient have the right to request an “accounting of disclosures.” An “accounting of disclosures” is a list of certain disclosures our company has made of your identifiable health information. In order to obtain an accounting of disclosures, you must submit your request in writing to Compliance Officer, at Tomlinson Pharmacy to the address on the front of this form. All requests for an “accounting of disclosures” must state a time period which may not be longer than six years and may not include dates before April 14, 2003. The first list you request within a 12 month period. Our organization will notify you of the costs involved with additional requests, and you may withdraw your request before you incur any costs.
Right to a Paper Copy of This Notice. You are entitled to receive a paper copy of notice of privacy practices which we provide for you at the time of delivery of your product. If you did not receive a copy with your prescription order, you may obtain a paper copy by calling or writing the Compliance Officer at the address above.
Right to File a Complaint. If you believe your privacy rights have been violated, you may file a complaint with our organization or with the Secretary of the Dept of Health and Human Services. To file a complaint with our organization. Compliance Officer, Tomlinson Pharmacy, I 08 Rowe St Dublin, GA 31021. All complaints must be submitted in writing. You will not be penalized for filing a complaint.
Right to Provide an Authorization for Other Uses and Disclosures. Our company will obtain your written authorization for uses and disclosures that are not identified by this notice or permitted by applicable law. Any authorization you provide to us regarding the use and disclosure of your identifiable health information may be revoked at any time in writing. After you revoke your authorization, we will no longer use or disclose your health information for the reasons described in the authorization. Please note that we are required to retain records of your care.