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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.
Schwieterman Pharmacies is required to
maintain the privacy of your Protected
Health Information ("PHI")
and to provide you with a notice of our legal duties and privacy practices
with respect to PHI. PHI is information about you, including basic
demographic information, that may identify you and that relates to
your past, present or future physical or mental health or condition
and related health care services. This Notices of Privacy Practices
("Notice") describes how we may use and disclose PHI about
you to carry out treatment, payment or
health care operations and for other specified purposes that are permitted
or required by law.
The Notice also describes your rights with
respect to PHI about you.
The Pharmacy is required to follow the
terms of this Notice. We will not use or
disclose PHI about you without your written
authorization, except as described in this
Notice. We reserve the right to change
our practices and this Notice and to make
the new Notice effective for all PHI we maintain. Upon
request, we will provide a revised Notice
to you.
- Obtain a paper copy of the Notice upon
request. You may request a copy of the
Notice at any time. Even if you have agreed
to receive the Notice Electronically, you
are still entitled to a paper copy. To
obtain a paper copy, contact Schwieterman
Pharmacies at 1-800-311-1612 or also available
at our website at
-Request a restriction on certain uses
and disclosures of PHI.You have the right
to request additional restrictions on our
use or disclosure of PHI about you by sending
a written request to Schwieterman Pharmacies
2 N. Washington St. New Bremen, Ohio 45869.
We are not required to agree to those restrictions.
-Inspect and obtain a copy of PHI. 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 Schwieterman Pharmacies 2 N. Washington
St. New Bremen, Ohio 45869.
We may charge you a fee for the costs of
copying, mailing, or other supplies that are necessary to grant 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.
-Request and amendment of PHI. If you feel
that PHI we maintain about you is incomplete
or incorrect, you may request that we amend
it. You may request and amendment for as
long as we maintain the PHI. To request
and amendment, you must send a written
request to Schwieterman Pharmacies 2 N.
Washington St. New Bremen, Ohio 45869.
In addition, 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 give you a rebuttal
to your statement.
-Request communications of PHI by alternative
means or at alternative locations. For
instance, you may request that we contact
you about medical matters only in writing
or at a different residence or post office
box. To request confidential communication
of PHI about you, you must submit your
request in writing to Schwieterman Pharmacies
2 N. Washington St. New Bremen, Ohio 45869.
Your request must state how or when you
would like to be contacted. We will accommodate
all reasonable requests.
The following categories describe and provide
examples of different ways that we use
and disclose PHI about you.
We will use PHI for treatment. Example:
Information obtained by the pharmacist
will be used to dispense prescription medications
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. Example: We
will contact your insurer or pharmacy benefit
manager to determine whether it will pay
for your prescription and the amount of
your co payment responsibility. We will
bill you or your third-party pay or 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.
Example: The Pharmacy may use information
in your health record to monitor the performance
of the pharmacists providing treatment
to you. This information will be used in
an effort to continually improve the quality
and effectiveness of the health care and
service we provide.
Communication with individuals involved
in your care or payment for your care:
Health professionals such as pharmacists,
using their professional judgment, may
disclose to a family member, other relative,
close personal friend or any person you
identify, PHI relevant to that person’s involvement in your
care or payment related to your care.
Food and Drug Administration (FDA): We
may disclose to the FDA or its agents PHI
relative to adverse events with respect
to drugs, foods, supplements, products
and product defects, or post marketing
surveillance information to enable product
recalls, repairs, or replacement.
Worker’s compensation: We may disclose PHI about you to the
extent authorized by and to the extent necessary to comply with laws
relating to worker’s compensation or other similar programs
established by law. Public health: As required
by law, we may disclose PHI about you to public health or legal authorities
charged with preventing
or controlling disease, injury, or disability.
Law enforcement: We may disclose PHI about
you for law enforcement purposes as required
by law or in response to a valid subpoena.
As required by law: We must disclose PHI
about you when required to do so by law.
Health oversight activities: We may disclose
PHI about you to an oversight agency for
activities authorized by law. These oversight
activities included audits, investigations,
and inspections, as necessary for our licensure
and for the government to monitor the health
care system, government programs, and compliance
with civil rights laws.
Judicial and administrative proceedings:
If you are involved in a lawsuit or a dispute,
we may disclose PHI about you in response
to a court or administrative order. We
may also disclose PHI about you in response
to a subpoena, discovery request, or other
lawful process by someone else involved
in the dispute, but only if efforts have
been made to tell you about the request
or to obtain an order protecting the requested
PHI.
We are permitted to use or disclose PHI
about you for the following purposes:
Research: We may disclose PHI about you
to researchers when their research has
been approved by an institutional review
board that has reviewed the research proposal
and established protocols to ensure the
privacy of your information.
Coroners, medical examiners, and funeral
directors: We may release PHI about you
to a coroner or medical examiner. This
may be necessary, for example, to identify
a deceased person or determine the cause
of death. We may also disclose PHI to funeral
directors consistent with applicable law
to carry out their duties.
Organ or tissue procurement organizations:
Consistent with applicable law, we may
disclose PHI about you 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 PHI
about you to notify or assist in notifying
a family member, personal representative,
or another person responsible for your
care, your location, and 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 health
and safety of the public or another person.
National security and intelligence activities:
We may release PHI about you to authorized
federal officials for intelligence, counterintelligence,
and other national security activities
authorized by law.
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 is necessary and
will not be used against you.
The Pharmacy will obtain your written authorization
before using or disclosing PHI about you
for purpose other than those provided for
above (or otherwise permitted or required
by law). You may revoke this 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.
If you have questions or would like additional;
information about the Pharmacy’s privacy practices, you may
contact Mark Dominik at 1-800-311-1612.
If you believe your privacy rights have been violated, you can file
a complaint with Mark Dominik
or with the Secretary of Health and Human
Services. There will be no retaliation for filing a complaint.
Effective Date
This Notice is effective as of 11/01/02.
Copies of privacy practices available
at each store.
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