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Notice
of Policy Receipt • Print
a copy of this notice for your records
Notice of Health Information Practices,
Gull Pointe Pharmacy, Inc.
Effective Date: April 1st, 2003
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.
- Understanding Your Health Record/ Information
Each time you visit our Pharmacy and receive a prescription, or
durable medical equipment that is billed to a third party, a record
is made of this encounter. Typically, this record contains medical
information from your referring physician, a prescription history,
as well as other information you provide to us. In this "Notice
of Health Information Practices," we shall refer to the Information
contained In your record as your "health information,"
which term shall have the same meaning as "protected health
Information," defined in the Health Insurance Portability
and Accountability Act of 1996, as amended ("HIPAA").
- Your Health Information Rights
Within the limits provided by federal and state law, you have
the right to:
- Request restrictions on certain uses and disclosures of
your health information;
Receive confidential communications of your health information.
You may request that we communicate with you about your health
Information by alternative means or at an alternative location;
- Inspect and obtain a copy of your health Information, except
with regard to psychotherapy notes or Information compiled
in reasonable anticipation of certain civil, criminal or administrative
proceedings;
- Request an amendment to your health Information that we
have created, except with regard to those portions of your
health Information that you are precluded from inspecting
and copying as set forth above;
- Obtain an accounting of certain disclosures of your health
information; and
Receive a paper copy of this Notice in addition to any electronic
copy you may receive.
You may exercise any of the above rights by submitting a written
signed letter, detailing your
request and mailing or delivering the letter to our Pharmacy.
However, we encourage you to
call first so that we can help you be as specific as possible
with your request. We
will promptly provide you with any forms that need to be completed
to process your request.
- Our Responsibilities
This Pharmacy is required by law to:
- Maintain the privacy of your health Information;
Provide you with this Notice of our legal duties and privacy
practices with respect to health Information we collect and
maintain about you;
- Abide by the terms of this Notice, Currently in effect,
and as amended from time to time;
Notify you if we are unable to honor your request to restrict
a use or disclosure of, or to amend, your health Information;
and
- Accommodate reasonable requests you may have to communicate
your health Information by alternative means or at alternative
locations.
We reserve the right to change our privacy practices and to make
the new provisions effective for all of your health Information
we already have, as well as any health information we receive
or create in the future, Should our privacy practices change,
we will post a copy of the revised Notice in our Pharmacy, which
indicates the effective date of the amended Notice, You may request
and obtain a copy of our Notice PC Privacy Practices anytime you
visit our office. If a use or disclosure of your health information
is not permitted under law without a written authorization, we
will not use or disclose your health information without that
written authorization, You may at any time revoke a written authorization
in writing, except to the extent that we have already taken action
in reliance of your authorization.
- For More Information or to Report a Problem
If you have questions and would like additional information concerning
this Notice, please call any of our Pharmacists at 269-553-5000.
If you believe that we have violated any of your privacy rights,
you may file a written complaint with any of our Pharmacists,
or mail your written complaint to Gull Pointe Pharmacy. Inc., 5585
Gull Rd., Kalamazoo, Mi., 49048. You may also file your complaint
with the Secretary of Health and Human Services. There will be
no penalty or retaliation for filing a complaint.
- Examples of Uses and Disclosures for Treatment, Payment and
Health Operations
The following are examples of uses and disclosures of your health
Information which are permitted by law:
- We will use your health Information for treatment. Health
Information obtained by our staff from you or one of your
health care providers, may be recorded in our medical records.
We may use this Information for many treatment reasons, including,
but not limited to, verifying the accuracy of prescriptions
being filled, and to help you avoid known drug allergies and
adverse drug interactions. Any of your prescriptions filled
in our Pharmacy, or purchases made at our Pharmacy, will be
recorded. We may also provide your health Information to other
health care providers involved in your care to assist them
on providing services to you. We will use your health plan
or health Insurer may require certain information about your
condition and/or the prescriptions you fill with us, before
payment will be made, or for pre-authorization purposes, Accordingly,
for billing purposes, we may disclose your health Information
to your health plan or health insurer.
- We will use your Health Information for regular health care
operations. Members of our staff
may review health Information in your record in order to assess
the care and outcomes in your case and others like It. This
Information will then be used In an effort to continually
Improve the quality and effectiveness of our services.
- Additional Uses and Disclosures
- Business Associates: Certain of our business operations
may be performed by other businesses. We refer to these companies
as "business associates." In order for these business
associates to perform the required service (billing, accounting
services, etc.), we may need to disclose your health information
to them so that they can perform the Job we've asked them
to do. To protect you, we require our business associates
to appropriately safeguard your health information.
- Communication with Persons Involved in Your Care: We may
disclose your health information that is directly relevant
to your care to individuals you wish to receive such Information,
Including family members, relatives, close personal friends,
or other persons you identify. Before we do so, we will ask
you, and follow your Instructions, as to whether or not to
make such disclosures. If you are Incapacitated, or Involved
In an emergency, we may use or make disclosures of your health
information that we believe in our professional judgment are
In your best interests, but only to the extent that such health
information is directly relevant to the recipients' involvement
In your care.
- Required By Law: We may use or disclose your health information
to the extent such use or disclosure Is required by law and
is limited to the relevant requirements of such law.
Public Health, Health Oversight and the Food and Drug Administration
(FDA): As required by law, we may disclose your health information
to public health or legal authorities charged with preventing
or controlling disease, injury, or disability. We may also
be required by law to disclose your health Information to
health oversight agencies responsible for regulating the health
care system, government benefit programs, and civil rights
laws so that they may conduct, among other things, audits,
investigations, and inspections. For the purpose of activities
relating to the quality, safety or effectiveness of a FDA-regulated
product or activity, we may disclose to the FDA your health
information relating to adverse events with drugs, supplements,
and other products, as well as Information needed to enable
product recalls, repairs, or replacements.
- Victims of Abuse, Neglect or Domestic Violence: If we reasonably
believe that you are the victim of abuse, neglect or domestic
violence, we may disclose your health Information to a governmental
Authority responsible for receiving these types of reports,
to the extent the disclosure is required by law, or you agree
to the disclosure, If the disclosure Is authorized by law,
but not required, we may disclose your Information If we determine
that disclosure Is necessary to prevent serious harm to you
or others,
- Judicial and Administrative Proceedings: If you are involved
in a judicial or administrative proceeding, we may, in
response to an order of a court or administrative tribunal,
or in response to a subpoena, discovery request, or other
lawful process, disclose the specific portions of your health
information that are requested. If the subpoena, discovery
request or other lawful process Is not accompanied by a court
or administrative tribunal order, we may disclose your health
information only after we are assured that reasonable efforts
have bean made to notify you of the request, and the time
for you to raise objections to the request has expired, or
reasonable efforts have been made by the requestor to seek
a protective Order concerning the requested health information.
- Law Enforcement: We may disclose your health information
to a law enforcement official for law enforcement purposes
as required by law, a court ordered subpoena or summons, a
grand jury subpoena or summons, or an administrative subpoena
or summons, under certain circumstances. In specific situations,
the law also permits us to disclose limited pieces of your
health information, when the information is needed by law
enforcement officials to; 1) identify a suspect, fugitive,
material witness, or missing person; 2) Identify a victim
of a crime; 3) alert law enforcement officials concerning
your death; 4) notify law enforcement Officials when a crime
has been committed on our premises; or 5) in an emergency,
when necessary to alert law enforcement officials about a
crime, Its location, or the identity of a perpetrator,
- Coroners, Medical Examiners and Funeral Directors: We may
disclose your health information to a coroner or medical examiner
for the purpose of Identifying you upon your passing, or to
determine a cause of death. We may also disclose your health
information to your funeral director if needed to complete
his or her authorized duties. Organ, Eye or Tissue Donation:
If you are an organ, eye or tissue donor, we may release your
health information to organizations that procure, bank or
transplant organs for the purpose of facilitating organ, eye
or tissue donation and transplantation.
- Research: We may disclose your health information to researchers
when their research has been approved by an Institutional
review board or privacy board that has reviewed the research
proposal and established protocols to ensure the privacy of
your health Information, thereby meeting the requirements
under HIPAA, We may also disclose your health information
for the purposes of research, public health or health care
operations pursuant to a Data Use Agreement protecting that
information as specified by HIPAA.
- Avert a Serious Threat to Health or Safety: Consistent
with applicable law and standards of ethical conduct, we may,
in limited circumstances, use or disclose your health information
if we, in good faith, believe such use or disclosure is necessary
to prevent or lessen a serious and imminent threat to health
or safety of a person or the public.
- Military Personnel: If you are a member of the United States
Armed Services, we may disclose your health Information to
the appropriate military command authority when such Information
Is deemed necessary to assure the proper execution of the
military mission. [Note - Additional disclosures are required
If you are a part of the Departments of Defense, Transportation,
Veterans Affairs, or State.]
- National Security and Presidential Protective Services:
We may disclose your health Information to authorized federal
officials for the conduct of lawful Intelligence and national
security activities, as well as the provision of protective
services to the President and other protected individuals.
Inmates and individuals In Custody: If you are an Inmate or
otherwise in custody, we may disclose your health Information
to the correctional facility or law enforcement official having
lawful custody of you.
- Worker's Compensation: We may disclose your health Information
to the extant authorized and necessary to comply with laws
relating to workers' compensation or other similar programs
established by law.
- Our Pledge
We will endeavor to protect the privacy of your health information.
If you have any questions, Comments, or concerns regarding the
policies set forth above, please do not hesitate to discuss such
matters with one of our Pharmacists,
Notice
of Policy Receipt • Print
a copy of this notice for your records
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