Notice of Privacy Practices

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.

As a part of the federal Health Insurance Portability and Accountability Act of 1996, known as HIPPA, the healthcare provider has created this Notice of Privacy Practices (Notice). This Notice describes the healthcare provider’s practices and the rights you, the individual, have as they relate to the privacy of your Protected Health Information (PHI). Your PHI is information about you, or that could be used to identify you, as it related to your past and present physical and mental health care services. The HIPPA regulations require that the healthcare provider protect the privacy of your PHI that the healthcare provider has received or created. The healthcare provider will abide by the terms presented within this Notice. For any uses or disclosures that are not listed below, the healthcare provider will obtain a written authorization from you that use or disclosure, which have will have the right to evoke at any time, as explained in more detail below. The healthcare provider reserves the right to change the healthcare provider’s privacy practices and this Notice. Revisions to the Notice will be posted in the healthcare provider and upon your request, provided to you in a paper format.

How the Healthcare Provider May Use and Disclose Your PHI

The following is an accounting of the ways that the healthcare provider is permitted, by law, to use and disclose your PHI.

• Uses and disclosures of PHI for Treatment: We will use the PHI that we receive from you to fill your prescription and coordinate or manage your health care.

• Uses and disclosures of PHI for Payment: The healthcare provider will disclose your PHI to obtain payment or
reimbursement from insurers for your health care services.

• Uses and disclosures of PHI for Health Care Operations: The healthcare provider may use the minimum necessary amount of your PHI to conduct quality assessments, improvement activities, and evaluate the healthcare provider workforce. The following is an accounting of additional ways in which the healthcare provider is permitted or required to use or disclose PHI about you without your written authorization. All uses and disclosures will be to the minimum necessary amount of your PHI. Many of these uses and disclosures will never be made by the healthcare provider; however, we are required by law to notify you of them as a health care provider.

• Uses and disclosures as required by law: The healthcare provider may use or disclose PHI about you as required and as limited by law.

• Uses and disclosure for Public Health Activities: The healthcare provider may use or disclose PHI about you to a public health authority by law to collect for the purpose or preventing or controlling disease, injury, or disability. This includes the FDA so that it may monitor any adverse effects of drugs, foods, nutritional supplements and other products as required by law.

• Uses and disclosure about victims of abuse, neglect or domestic violence: The healthcare provider may use or disclose PHI about you to a government authority if it is reasonably believed you are a victim or abuse, neglect or domestic violence.

• Uses and disclosure for health oversight activities: The healthcare provider may use or disclose PHI about you to a health oversight agency for oversight activities which may include audits, investigations, inspections as necessary for licensure, compliance with civil laws, or other activities the health oversight agency is authorized by law to conduct.

• Disclosures for judicial and administrative proceedings: The healthcare provider may disclose PHI about you in the course of any judicial or administrative proceedings, provided that proper documentation is presented to the healthcare provider.

• Disclosures for law enforcement purposes: The healthcare provider may disclose PHI about you to law enforcement officials for authorized purposes as required by law or in response to a court order or subpoena.

• Uses and disclosures for research purposes: The healthcare provider may use and disclose PHI about you for research purposes with a valid waiver of authorization approved by an institutional review board or privacy board. Otherwise, the healthcare provider will request a signed authorization by the individual for all other
research purposes.

• Uses and disclosures to avert a serious threat to health or safety: The healthcare provider may use or disclose PHI about you, if it is believed in good faith, and is consistent with any applicable law and standards of ethical conduct, to avert a serious threat to health or safety.

• Uses and disclosures for specialized government functions: The healthcare provider may use or disclose PHI about you for specialized government functions including; military and veteran’s activities, national security and intelligence, protective services, department of state functions, and correctional institutions and law enforcement custodial situations.

• Disclosure for workers’ compensation: The healthcare provider may disclose PHI about you as authorized by and to the extent necessary to comply with workers’ compensation laws or programs established by law.

• Disclosures for disaster relief purposes: The healthcare provider may disclose PHI about you as authorized by law to a public or private entity to assist in disaster relief efforts.

• Disclosures to business associates: The healthcare provider may disclose PHI about you to the healthcare provider’s business associates for services that they may provide to you or for the healthcare provider to assist the healthcare provider to provide quality health care. To ensure the privacy of your PHI, we require all business associates to comply with appropriate safeguards to any PHI they receive or create.

Other Uses and Disclosures

The healthcare provider may contact you for the following purposes:

• Refill reminders: The healthcare provider may contact you to remind you of your prescription upon such time they are ready to be refilled.

• Information about treatment alternatives: The healthcare provider may contact you to notify you of alternative treatments and/or products.

• Health related benefits or services: The healthcare provider may use your PHI to notify you of benefits and services the healthcare provider provides.

• Fundraising: If the healthcare provider participates in a fundraising activity, the healthcare provider may use demographic PHI to send you a fundraising packet, or the healthcare provider may disclose demographic PHI about you to its business associate or an institutionally related foundation to send you a fundraising packet. No further disclosure will be allowed by the business associate or an institutionally related foundation without your written authorization.

For All Other Uses and Disclosures

The healthcare provider will obtain a written authorization from you for all other uses and disclosures or PHI and the healthcare provider will only use or disclose pursuant to such an authorization. In addition, you may revoke such an authorization in writing at any time. To revoke a previously authorized use or disclosure, please contact our Privacy Officer to obtain a Request for Restriction of Uses and Disclosures.

Your Health Information Rights

The following are a list of your rights in respect to your PHI.

• Request restrictions on certain uses and disclosures of your PHI: You have the right to request additional restrictions of the healthcare provider’s uses and disclosures of your PHI; however, the healthcare provider is not required to accommodate a request. If you wish to request additional restrictions, please obtain the form, Request for Restriction of Uses & Disclosures, from the healthcare provider and return the completed form to the healthcare provider or return to our Privacy Officer.

• The right to have your PHI communicated to you by alternate means or locations: You have the right to request that the healthcare provider communicate confidentially with you using an address or phone number other than your residence. However, state and federal laws require the healthcare provider to have an accurate address and home phone number in case of emergencies. The healthcare provider will consider all reasonable requests. If you wish to change in your communicating address and/or phone number, please obtain a form, Request for Alternative Arrangements for Confidential Communication, from the healthcare provider and return the completed form to the healthcare provider or return to our Privacy Officer.

• The right to inspect and/or obtain a copy of your PHI: You have the right to request access and/or obtain a copy of your PHI that is contained in the healthcare provider for the duration the healthcare provider maintains PHI about you. If you wish to inspect or obtain a copy of your PHI, please obtain a form, Request for Access to Records, from the healthcare provider and return the completed form to the healthcare provider or return to ur Privacy Officer. There may be a reasonable cost-based charge for photocopying documents. You will be notified in advance of incurring such charges, if any.

• The right to amend your PHI: You have the right to request an amendment of the PHI the healthcare provider maintains about you, if you feel that the PHI the healthcare provider has maintained about you is incorrect or otherwise incomplete. Under certain circumstances we may deny your request for amendment. If we do deny the request, you will have the right to have the denial reviewed by someone we designate who was not involved in the initial review. You may also ask the Secretary, United State Department of Health and Human Services (“HHS”), or their appropriate designee to review such a denial. If you wish to amend your PHI files, please obtain a form, Request for Amendment to PHI, from the healthcare provider and return the completed form to the healthcare provider or return to our Privacy Officer.

• The right to receive an accounting of disclosures of your PHI: You have the right to receive an accounting of certain disclosures of your PHI made by the healthcare provider. If you wish to receive an accounting of disclosures of your PHI, please obtain a form, Request for Accounting of Disclosures, from the healthcare provider and return the completed form to the healthcare provider or return to our Privacy Officer. You should be aware, however, that such an accounting excludes uses and disclosures made for treatment, payment, or health care operations purposes.

• The right to receive additional copies of the healthcare provider’s Notice of Privacy Practices: You have the right to receive additional paper copies of this Notice, upon request, even if you initially agreed to receive the Notice electronically. If you wish to receive a paper copy of this request, please ask a healthcare provider workforce member and they will provide you with a copy.

Revisions to the Notice of Privacy Practices

The healthcare provider reserves the right to change and/or revise this Notice and make the new revised version applicable to all PHI received prior to its effective date. The revised Notice will be available, upon request, to all individuals. The healthcare provider will also post the revised version of the Notice in the healthcare provider.

Complaints

If you believe your privacy rights have been violated, you may file a complaint with the healthcare provider and/or the Secretary of HHS, or his designee. If you wish to file a complaint with the Secretary, please write to:

Hubert H. Humphrey
Building 200 Independence Avenue SW
Washington, D.C. 20201

If you wish to file a complaint with the healthcare provider, please contact our Privacy Officer:

GrandView Pharmacy
Attn: Privacy Officer
474 Southpoint Circle
Brownsburg, IN 46112
866.827.7575

The healthcare provider will not take any adverse action against you as a result of your filing of a complaint.

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