57 Pond Street
Ludlow, VT 05149
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.
DATE OF NOTICE: April 14, 2003
SECTION A: Uses and Disclosures of Protected Health information
1.) 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”). We are also required to provide you with this Notice regarding our policies and procedures regarding your Protected Health Information 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. We may obtain information to dispense prescriptions and for the documentation of pertinent information in your records that may assist us in managing your medication therapy of your overall health. For treatment purposes, such use and disclosure will take place in providing, coordinating, or managing healthcare and it’s related
services by one or more of your providers, such as when your pharmacist consults with your physician or a specialist regarding your medications, treatments 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 that appropriate care was rendered. For reimbursement purposes, your Protected Health Information 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; and planning, development, management and administration. Your information could be used, for example, to assist in the evaluation of the quality of care that you were provided.
We store some of your Protected Health Information in electronic computer files. We backup our electronic records daily, and employ other precautions to safeguard the integrity of your Protected Health Information. In spite of these precautions it is possible but unlikely that a computer crash or other technological failure could cause the loss of data. In addition reasonable safeguards are employed to protect your Protected Health Information stored on electronic media.
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.
We may use and disclose your Protected Health Information, without your authorization when the pharmacy needs to contact a physician or physicians staff and is permitted or required to do so without individual written authorization. We may use and disclose your Protected Health Information 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 Protected Health Information. Business associates are required to comply with all the privacy regulations on your behalf.
We may disclose Protected Health Information about you without your authorization to comply with workers compensation laws, as required by law enforcement, legal proceedings, public health requirements, health oversight activities and as required by law.
Other uses and disclosures will be made only with your written authorization, and you may revoke your authorization by notifying us as described in Section B
2.) You may ask us to restrict uses and disclosures of your Protected Health Information to carry out treatment, payment, or healthcare operations, or to restrict uses and disclosures to family members, relatives, friends, or the 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.
3.) You have the right to request the following with respect to your Protected Health Information:
(i) inspection and copying; (ii) amendment or correction; (iii) an accounting of the disclosure of this information by us (we are not required to account to you for disclosures made for treatment, payment, operations, and disclosures to you, disclosures to your care givers, for notifications or as otherwise excluded by law); and (iv) the right to receive a paper copy of this notice upon request. We may require you to pay for this request to cover our costs of copying, labor and
In addition, you may request, and we must accommodate the request, if reasonable, to receive communications of Protected Health Information by alternative means or at alternative locations. To make this request please contact in writing.
57 Pond Street
Ludlow, VT 05149
4.) We may use your name to reference your prescriptions and pharmaceutical care services. You may be required to sign a signature log form to acknowledge receipt of service, to acknowledge receipt of this Notice and the disclosure of Protected Health Information as outlined herein. This information may be disclosed by us 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 restrictions or prohibitions. We are not required to honor those requests. We are able to provide treatment services to you even if you object to sign the acknowledgement of the receipt of this Notice or if we decide not to honor a request regarding the information in this document. 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 if uses and disclosures would require your signed authorization under such circumstances and give you an opportunity to object as soon as practicable.
5.) 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, Protected Health Information that is directly relevant to the person’s involvement with your care or payment related to your care. In addition we may use or disclose the Protected Health Information 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 in our judgment what 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 other similar forms of Protected Health Information.
6.) We reserve the right to change the terms of this Notice and to make new Notice provisions effective for all Protected Health Information we maintain. You may receive a copy of this Notice by contacting us as outlined in Section B or upon the receipt of pharmacy care services.
7.) If you believe that your privacy rights have been violated, you may complain to 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
Avenue SW, Washington, DC 20201.
You will not be retaliated against for filling a complaint.
Section B: Contacting Us
You may contact us for further information at:
57 Pond Street
Ludlow, VT 05149