This notice serves to inform you of your rights under the Health Insurance Portability & Accountability Act Privacy Rule (HIPPA). It is enforced by the Office of Civil Rights, Department of Health and Human Services. 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.

1. How we may use and disclose protected health information (PHI).

We will use PHI for treatment. Information obtained by the pharmacist will be use to dispense prescription medication to you. We will document in your record information related to the medications dispensed to you and services provided to you.

We will use PHI for payment. We will contact your insurer or pharmacy benefit manager to determine payment for your prescription and the amount of your co-payment. We will bill you or a third party payor for the cost of prescription medications dispensed to you. The information on or accompanying the bill may include information that identifies you, as well as the prescriptions you are taking.

We will use PHI for health care operations. We may use information in your health record for quality assessment, auditing, developing policies, and for business management.

We may use or disclose PHI for the following purposes:

Business associates- There are some services provided by us through contracts with business associates. These may include health care plans, clearinghouses, or health care providers that maintain or transfer health, financial and administrative information in electronic format. Other examples include services provided on our behalf by Martin’s IGA Plus, Pharmacist liability insurers and collection agencies. When these services are contracted for, we may disclose PHI about you to our business associates so they can perform the job we have asked then to do and bill you or your third-party payor for services rendered. To protect PHI, we require business associates to appropriately safeguard the PHI.

Health-related communications- We may contact you to provide refill reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you.

Worker’s compensation- We may disclose PHI about you as authorized by and as necessary to comply with laws relating to worker’s compensation or similar programs established by law.

Law enforcement- We may disclose PHI about you for law enforcement purposes as required by law or in response to a valid subpoena or other legal process.

As required by law- We must disclose PHI about you when required by law to do so by law.

We are permitted to use or disclose PHI about you for the following purposes:

Notification- We may use or disclose PHI about you to notify or assist in notifying a family member, personal representative, or another person responsible for your care, your location, and your general condition.

To avert a serious threat to health or safety- We may use and disclose PHI about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person.

Victims of abuse, neglect, or domestic violence- We may disclose PHI about you to a government authority, such as a social service or protective services agency, if we reasonably believe you are a victim of abuse, neglect, or domestic violence. We will only disclose this type of information to the extent required by law, if you agree to the disclosure, or if the disclosure is allowed by law and we believe it is necessary to prevent serious harm to you or someone else or the law enforcement or public official that is to receive the report represents that it is necessary and will not be used against you.

Other uses and disclosures of PHI

The Pharmacy will obtain your written authorization before using or disclosing PHI about you for purposes other than those provided for above or as otherwise permitted or required by law. You may revoke an authorization in writing at any time. Upon receipt of the written revocation, we will stop using or disclosing PHI about you, except to the extent that we have already taken action in reliance on the authorization.

2. Security of protected health information.

The designated privacy compliance officer responsible for the development and implementation of the policies and procedures regarding HIPAA for our pharmacy is Jeff Lakins. You may contact him at our pharmacy for further information or complaints.

A good faith effort will be made by our entire staff to protect private health information that is discussed and/or written in our pharmacy among employees and with our customers.

Customer records are kept in a secure area that is monitored by employees and locked when our pharmacy is closed.

All employees are trained on policies and procedures with respect to protected health information. They are required to sign a confidentiality statement. A policy dealing with employees who breech confidentiality in this pharmacy is in place.

We reserve the right to make changes in our privacy practices stated in this notice for protected health information and implement them in our pharmacy. Revisions to the privacy notice will be distributed in a timely manner to you.

3. Your Health Information Rights

You have the right to request additional restrictions on our use or disclosure of PHI about you by sending a written request to the Privacy Officer at the Pharmacy. We are not required to agree to those restrictions.

You have the right to access and copy PHI about you contained in a designated record set for as long as the Pharmacy maintains the PHI. The designated record set usually will include prescription and billing records. To inspect or copy PHI about you, you must send a written request to the Privacy Officer at the Pharmacy. We may charge you a fee for the costs of copying, mailing and supplies that are necessary to fulfill your request.
We may deny your request to inspect and copy in certain limited circumstances. If you are denied access to PHI about you, you may request that the denial be reviewed.

You may request an amendment for as long as we maintain the PHI if you feel your PHI is incomplete or incorrect. To request an amendment, you must send a written request to the Privacy Officer at the Pharmacy. You must include a reason that supports your request. In certain cases, we may deny your request for amendment. If we deny your request for amendment, you have the right to file a statement of disagreement with the decision and we may give a rebuttal to your statement.

You have the right to receive an accounting of the disclosures we have made of PHI about you after April 14, 2003 for most purposes other than treatment, payment, or health care operations. The accounting will exclude certain disclosures, such as disclosures made directly to you, disclosures you authorize, disclosures to friends or family members involved in your care, and disclosures for notification purposes. The right to receive an accounting is subject to certain other exceptions, restrictions, and limitations. To request an accounting, you must submit a request in writing to the Privacy Officer at the Pharmacy. Your request must specify the time period, but may not be longer than six years. The first accounting you request within a 12 month period will be provided free of charge, but you may be charged for the cost of providing additional accountings. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time.

You may request a copy of the Notice at any time. To obtain a paper copy, contact the Privacy Officer, Jeff Lakins RPh., at the Pharmacy, 101 S. Merchant, Effingham, IL. 62401. For more information or if you believe your privacy rights have been violated contact the Privacy Officer. You can file a complaint with the Privacy Officer or with the Secretary of Health and Human Services. There will be no retaliation for filing a complaint.

This notice is effective as of April 14, 2003, and is considered renewable at one-year intervals on the anniversary date, unless terminated, in writing, by either party upon ninety days written notice.