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.
DATE OF NOTICE: April 14, 2003
SECTION A: Uses and Disclosures of Protected
Health Information
1. 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.
We 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. Prescriptions and health supplies may be picked up by or delivered
to family members or personal representatives unless otherwise prohibited in
writing by you. Delivered prescriptions may be authorized to be left at your
delivery address if you are unable to answer upon delivery.
For 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.
Medical expense statements will be provided to family members on your behalf
unless you specifically notify us that you prohibit such disclosure.
For 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;
and 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. Health care screening and wellness activities in the pharmacy
or at remote locations will be conducted and results divulged in a manner as
conducive to privacy as physically possible.
We 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.
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.
In addition, we may disclose your health information to your plan sponsor. In
addition we may contact you for the purpose of fund raising activities.
We 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.
From 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.
We 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.
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 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.
3. 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 postage.
In 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:
John D. Krick, R.Ph.
Privacy Officer
Meadow Lane Pharmacy
912 No. 70th Street
Meadow Lane Pharmaceutical Compounding
914 No. 70th Street
Lincoln, NE 68505
(402) 489-0220
www.meadowlanepharmacy.com
email: mlpharmacy@alltel.net
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 Protected
Health Information 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 circumstances
and give you an opportunity to object as soon as practicable. person’s
5. 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 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 Health Information.
6. 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.
7. 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, Hubert H. Humphrey Building, 200 Independence
Avenue SW, Washington, DC 20201. You will not be retaliated against for filing
a complaint.
Section B: Contacting Us
You may contact us for further information at:
John D. Krick, R.Ph.
Privacy Officer
Meadow Lane Pharmacy
912 No. 70th Street
Meadow Lane Pharmaceutical Compounding
914 No. 70th Street
Lincoln, NE 68505
(402) 489-0220
www.meadowlanepharmacy.com
email: mlpharmacy@alltel.net