Fallon Pharmacy
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HIPAA

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. 

Section A: How Fallon Wellness Pharmacy May Use or Disclose Your Health Information

 1. Under current Federal and State Law, we are required to protect the privacy of your personal health information.  This type of personal health information is referred to as protected health information or (PHI).  We are also required to supply you with this notice regarding our policies and procedures concerning your PHI. This notice is subject to change in order to comply with evolving patient privacy laws.  If changes to current policies and procedures are made you will be notified of such changes.

  • We are permitted by applicable law to use and disclose PHI for the purposes of treatment, payment, and healthcare operations.  Information may be obtained in order to dispense prescriptions and for documentation of applicable information in our records that may aid us is supplying you with quality care.  For treatment purposes your PHI may be discussed with your providers in order to optimize therapy. 
  • For payment purposes, use and disclosure will take place to obtain reimbursement for providing pharmaceutical care services.  For reimbursement purposes your PHI may be disclosed to one of several intermediaries employed by your plan sponsor including insurers, pharmacy benefits managers, and claims administrators.  PHI will NOT be disclosed to your plan sponsor if payment is strictly paid out of pocket and no reimbursement from the insurer is necessary.
  • For healthcare purposes, such use and disclosure will take place in a number of ways including: quality assessment and improvement, provider review and training, reviews and compliance activities, and planning.  For example, your PHI may be utilized to assist in the evaluation of the quality of care that you were provided. 
  • We store some of your PHI in electronic computer files.  In order to protect these electronic files, we employ precautions and safeguards that promote the integrity of our electronic systems. 
  • We may use and disclose your PHI if we are contacted by another pharmacy who states they have your request and consent to transfer pharmacy records to them. 
  • 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.  You may also be contacted for the purpose of fund raising activities. 
  • Occasionally we may employ the services of business associates who may assist us in one or more tasks and who may use, change or create PHI.  Business associates are required to comply with the privacy regulations on your behalf. 
  • We may disclose PHI about you without your authorization to comply with workers compensations 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 PHI to carry out treatment, payment, or healthcare operations, or to restrict uses and disclosures to family members, relatives, friends, or other persons who are involved in 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 PHI: 1. Inspection and copying, 2. Amendment or correction, 3. An accounting of the disclosures of this information made by us (we are not required to account to you the disclosures made to treatment, payment, operations, disclosures to you, disclosures to your care givers, for notifications or as otherwise excluded by law), 4. The right to receive a paper copy of this notice upon request.  In addition, you may request, and we must accommodate the request, if reasonable, to receive communications of PHI by alternative means or at alternative locations. To make this request please contact use ad described in section B.

 

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 PHI 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 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 circumstance 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 any other person identified by you, PHI 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 PHI 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 allowing people to pick-up fill prescriptions, or other similar forms of PHI.

6. We reserve the right to change the terms of this notice and to make new notice provisions effective for all PHI 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 contact use regarding the situation as described in section B.  You may also contact the Secretary of the Department of Health and Human Services, Hubert H. Humphrey Building, 200 Independence Avenue SW, Washington, DC 20101. You will not be retaliated against for filing a complaint.

Section B:  Contacting Us

For further information we can be contacted at:

Fallon Wellness Pharmacy

1057 Troy-Schenectady Road, Latham, NY 12110

(518) 220-2005     (800) 890-1137

(518) 220-5004 Fax

 

Name:                                                                                                                  _          

 

Date:                                                     _

 

Signature:                                                                                                            _