The Health Insurance Portability and Accountability Act (“HIPAA”)
NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW IF CAREFULLY.
This Notice of Privacy Practices (the Notice) describes the privacy practices of Lee Silsby Compounding Pharmacy (“LSCP”).
Lee Silsby Compounding Pharmacy wants you to know that nothing is more important to our operation than maintaining the privacy of your health information (“Protected Health Information” or “PHI”). We take the responsibility of protecting your PHI. This information includes basic information that may identify you and relates to your past, present and future health or condition and the dispensing of pharmaceutical products or related services related to your health.
Our Pledge Regarding Your Health Information
We are requires by federal and state laws, regulations and other authorities to protect the privacy of your health information and to provide you with this Notice. Our pharmacy staff has been trained to protect the confidentiality of your PHI and will disclose your PHI to a person other than yourself or your authorized representative without your written permission, only when permitted under federal or state law. This extends to any PHI that is oral, written or electronically received by this pharmacy. This Notice describes how we may use and disclose your PHI.
This Notice also describes your rights and the obligations we have regarding the use and disclosure or your PHI. Under federal and applicable state law. We are required to follow the terms of this Notice currently in effect.
HIPAA’s standards may be pre-empted by certain state laws relating to the privacy of health information. These are reviewed at the end of this notice.
How we may use or disclose your PHI without your permission
TREATMENT, PAYMENT OR HEATLHCARE OPERATIONS MAY REQUIRE THE RELEASE OF YOUR PHI WITHOUT YOUR WRITTEN PERMISSION AS DESCRIBED BELOW.
- Treatment: Dispensing medications: PHI obtained by LSCP will be used to dispense prescription medication. We will document information related to the medication (s) dispensed and services provided in your record. We may contact you to provide treatment related services, such as how a medication is working for you, prescription refills , treatment alternatives and other health related services that mat be of interesr or benefit to you.
- Payment: We may contact your insurer, payor or other agent and share your PHI with that enity to determine whether it will pay for a prescription or service and to what amount. We may also contact you about a payment or balance due for prescription dispensing or service give.
- Health care opertations: Your PHI may be used to monitor the effectiveness of a service.
OTHER SPECIAL CIRCUMSTANCES
We are permitted under federal and applicable state law to use or disclose your PHI without your permission , only when certain circumstances may arise, as described below.
We are likely to use or disclose your PHI for the following purposes:
Business Associates: We provide some services through other companies termed “Business Associates”. Federal law requires us to enter into business associate contract to safeguard your PHI as required by LSCP and by law.
Individuals involved in your care or payment for said care: We may disclose your PHI to a family member, personal representative or friend involved in your medical care. If we can resonably infer that you agree that the related information be given to the caregiver on your behalf.
Disclosures to parents or legal guardians: If you are a minor, we may release your PHI to your parents or legal guardians when we are permitted or required under federal or applicable state law.
Workers compensation: We may disclose your PHI to the extent authorized and necessary to comply with the laws relating to workers compensation or simlar estalished law.
Law enforcement: We may disclose your PHI for law enforcement purposes, as required by law or in response to a court order, subpoena, warrant, summons or similar process; to identify or locate a suspect, fugitive, material witness or missing person; about a crime related to the business or on the premises; and in emergency circustances, to report a crime, the location, victim, or identity, description, or location of the perpe-trator of a crime.
As required by law: We must disclose your PHI when required to do so by applicable federal or state law.
Judicial and administrative proceedings: If you are involved in a lawsuit or legal dispute, we may disclose your PHI in response to a court order or administrative order, subpeona, discovery, request or other lawful process.
Public Health: We may disclose your PHI to federal, state, or local authorities or other entities charged with preventing or controlling disease, injury, or disability for public health activities. These activities may include the following: disclosures to report reactions to medications or other products to the U.S. Food and Drug Administration or other authorized entity. Disclosure to notify individuals of recall, exposures to a disease, or risk for contracting or speading a disease or condition.
United States Department of Health and Human Services (HHS): Under federal law, and if a request has been made, we are required to disclose your PHI to HHS to determine if we are compliant with federal laws and regulations regarding the privacy of health information.
Coroners, medical examiners, and funeral directors: We may release your PHI to assist in identifying a deceased person or determine a cause of death.
Administrator or executor: Upon your death we may disclose your PHI to an administator, executor, or other individual so authorized under applicable state laws.
Organ or tissue procurement organizations: Consistant with applicable law, and if your will so states, we may disclose your PHI to organ procurement organizations or other entities engaged in the procurement, banking, or transplantation of organs for the purpose of tissue donation and transplant.
Notification: We may use or disclose your PHI to assist in a disaster relief effort so that your family, personal representative, or friends may be notified about your condition, status and location.
Correctional institution: If you are or become an inmate of a correctional facility, we may disclose to the facility or to its agents PHI necessary for your health and the health and safety of others.
To avert a serious threat to health or safety: We may use and disclose your PHI to appropriate authorities when necessay to prevent a serious threat to your health and safety or the health and/or safety of another person or the public.
National security and intelligence activities: We may release your PHI to authorized federal officials for intelligence, counterintelligence and other national security activities authorized by law.
Military and veterans: If you are a member of the armed forces, we may release your PHI as required by military command authorities. We may also release PHI about foreign military personnel to the appropriate military authority.
Protective services for the President and others: We may disclose your PHI to authorized federal officials so that they may provide protection to the President, other authorized persons, or foreign heads of state, or conduct special investigations.
How We May Use or Disclose Your PHI For Other Purposes Only With Your Authorization
We will obtain your written permission before using or disclosing your PHI for purposes other that those described above (or as otherwise permitted or required by law}. You may revoke this authorization at any time by submitting a written notice to our Privacy Officer at the address listed below. Your revocation will become effective upon our reciept of your written notice.
You have the following right with respect to your PHI:
Obtain an additional paper copy of the Notice of Privacy (PHI) upon request. To obtain a copy contact LSCP Privacy Officer at the telephone or address listed below.
Inspect and obtain a copy of your PHI. You have the right to access and copy your PHI contained in the “designated record set,” which includes prescriptions, billing records and any forms that have been filled out by you or pharmacy personnel contained within. To inspect or review your PHI must be done in writing to the LSCP/ Privacy Office. A fee may be charged for the expense of fulfilling your request. We may deny your request to inspect and copy in certain limited circumstances. To the extent your information is held in an electronic health record, you may be able to receive the information in an electronic format. We will respond to your request within 30 days. If we deny your request, we will notify you in writing and provide you with the opportunity to request a review of the denial.
Request an amendment of PHI. If you feel that your PHI is incomplete or incorrect, you may request that we amend it for as long as we maintain the PHI. To request an amendment, submit a written request to LSCP/ Privacy Officer. Requests must identify: (1) which information you seek to amend, (2) what correction you would like to make, and (3) why the information need to be amended. We will respond to you in writing within 60 days (with a possible 30 day extension). In our response, we will either (1) agree to make the amendment, or (2) inform you of our denial, explain our reason and outline appeal procedures. If denied, you have the right to file a statement of disagreement with the decision. We will provide a rebuttal to your statement and maintain appropriate records of your disagreement and our rebuttal in your PHI.
Right to an accounting of disclosures of PHI. You have the right to receive an accounting of certain disclosures of your protected health information. The accounting will exclude disclosures: made directly to you, made with your authorization, made incidentally, made to caregivers, made for notification purposes, for national security and certain other disclosures. To obtain accounting, sumit a written request to the LSCP/ Privacy Officer. Request must specify the time period, not to exceed six years. We will respond in writing within 60 days of reciept of your request (with a possible 30 day extension). We will provide an accounting per 12 month period free of charge, but you may be charged for the cost of any subsequent accounting. We will notify you in advance of the cost involved, and you may choose to withdraw or modify your request at that time.
Request communications of PHI by alternative means or at alternative locations. You have the right to request that we communicate with you in a certain way or at a certain location. For example, you may request that we contact you only in writing at a specific address. To request confidential communication of your PHI, submit a written request to the LSCP/ Privacy Officer. Request must state how, where, or when you would like to be contacted. We will accommodate all reasonable requests.
Right to be notified of a breach. You have the right to be notified in the event that we (or one of our Business Associates) discover a breach of your unsecured protected health information. To obtain a paper copy of this notice, contact us in righting to the listing below.
Request a restriction on certain uses and disclosures of PHI. You have the right to request a restriction or limitation on our use or disclosure of your PHI by submittiing a written request to the LSCP/ Privacy Officer. You must identify in the request (1) what particular information you would like to limit, (2) to whom you want to limit use, disclosure or both, and (3) to whom you want the limits to apply. All requests will be carefully considered, but we are not required to agree to those restrictions. We will provide you with a written response within 30 days of your request. If we do agree to restrict use or disclosure of your PHI, we will not apply these restrictions in the event of an emergency. We also have the right to terminate the restriction if: (1) you agree orally or in writing , or (2) we inform you of the termination, which becomes effective only with respect to your PHI created or recived after we inform you of termination.
Contact the Lee Silsby Compounding Pharmacy (LSCP) / Privacy Officer at 3216 Silsby Road, Cleveland Hts., Ohio 44118. Call us 1-800-918-8831. Our fax is (216)321-4303 or e-mail us at email@example.com. All request for PHI must include patient full name, date of birth and address.
Complaints. If you believe your privacy rights have been violated, you may file a complaint with the LSCP/ Privacy Officer at the above address or with the Secretary of the United States Department of Health and Human services. All complaints must be submitted in writing . You will not be penilized in any way for filling a complaint.
Changes to this Notice: We reserve the right to change our privacy practices. We reserve the right to make changes to the Notice of Privacy. We reserve the right to make the revised Notice effective for PHI we already have about you as well as any information we receive in the future, as the effective date of the revised Notice. Upon request to the Privacy Officer, LSCP will provide a revised Notice to you.
Effective Date: This revised Notice is effective 9/19/14
State of Ohio Specific Provisions:
Disclosure Unless we have obtained your writen consent, we will only disclose your pharmacy records to: (a) you; (b) the prescriber who issued the prescription or medication order, or their authorized staff; (c) certified/licensed health care personnel who are resposible for your care; (d) a member, inspector, agent or investigator of the state board of pharmacy or any federlal, state, municipal officer whose duty is to enforce the laws of Ohio or the United Stats of America relating to drugs and who engaged in a specific investigation involving a designated person or drug; (e) an agent of the state medical board when enforcing the statutes governing physcians and limited practioners; (f) an agency of government charged with the responsibilty of providing medical care for you, upon written request by an authorized representative of the agency requesting such information; (g) an agent of a medical insurance company who provides prescription insurance coverage to you, upon authorization and proof of insurance by you or proof of payment by the insurance company for those medications whose information is requested; (h) an agent who contracts with the pharmacy as a “Business Associate” in accordance with the regulations promulgated by the Secretary of the United States Department of Health and Human Services pursuant to the federal standards for privacy of individually identifible health information; or (i) in emergency situations, when in your best interest.
This is revision III done and effective September 19, 2014