724 Main Street
101 W. Rochester Street
Notice of Privacy Practices
Date of Notice:
April 14, 2003
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Describes How Medical Information About You May Be Used And Disclosed
And How You
Can Get Access To This Information.
Review It Carefully
All of us at Webb’s
Family Pharmacy value your relationship with us, and we know that respect for
your privacy is the foundation of that relationship. We are committed to
protecting the privacy of your protected health information
(PHI) that is in our possession, and only using and disclosing your PHI as
necessary to providing you with health care products and services. PHI is any
information that we possess, use, and disclose that identifies you and relates
to your past, current, or future physical and mental health condition or illness
and the health care products and services that have been provided to you.
“Notice of Privacy Practices” (Notice) has been created to help you
understand our legal duties to protect your PHI and how we may use and disclose
your PHI in relation to your past, present, and future health condition and its
treatment. We will mainly use and disclose your PHI in relation to the health
care products and services that we provide you, such as dispensing your
prescriptions. Specifically, we will use and disclose your PHI as necessary to
provide treatment to you, obtaining payment for health care products and
services provided to you, and other health care operations and activities as
described later in this Notice. This Notice also describes the legal rights that
you have related to your PHI that is in our possession. We take the matters
described in this Notice very seriously because of our relationship with you and
the requirement that we comply with this Notice.
PHI will only be used and disclosed as described in this Notice. Should a need
for use and disclosure of your PHI occur that is not described in this Notice,
we will obtain your written authorization before the use and disclosure. At some
future time, it may be necessary for us to revise this Notice. If such becomes
necessary, we will post the revised Notice in the pharmacy and, if you request,
provide a written Notice to you.
That We May Use and Disclose Your PHI
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.
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 or your overall health.
For treatment purposes, such use and disclosure 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.
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.
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 that you were provided.
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.
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
may use and disclose your Protected Health Information, 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
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.
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.
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.
Permitted or Required by Law: Information about you may be used or disclosed to
regulatory agencies, such as during audits, licensure or other proceedings; for
administrative or judicial proceedings; to public health authorities; or to law
enforcement officials, such as to comply with a court order or subpoena.
uses and disclosures will be made only with your written authorization, and you
may revoke your authorization by notifying us at the address below.
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 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 Protected Health Information: (i) inspection and
copying; (ii) amendment or
correction; (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, 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
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 at the address below:
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.
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.
We are able to provide treatment services to you even if you object to
sign the acknowledgment 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.
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
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.
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,
200 Independence Avenue SW
will not be retaliated against for filing a complaint.
You may contact us
for further information at: Webb’s Family Pharmacy, INC, Harry Webb, Owner,
724 Main Street
; Phone 574-223-2216, Fax 574-223-3987; or Contact
Again, thank you
for allowing us the privilege of being your pharmacy, and we look forward to
continuing to be of service to you.
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