PATHSTONE HEALTH SERVICES PHARMACY 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.

From time to time, your Pathstone Health Services pharmacy (the “Pharmacy”) uses and discloses confidential personal health information called protected health information (“PHI”). The Pharmacy is required to protect the privacy of your PHI and to provide you with notice of the Pharmacy’s legal duties and privacy practices with respect to PHI. This Notice describes how the Pharmacy may use and disclose your PHI and certain rights you have with respect to your PHI. This Notice is required by the federal privacy regulations issued under the Health Insurance Portability and Accountability Act of 1996 (the “HIPAA Privacy Rule”). Please also see the Addendum below which provider certain information concerning applicable state laws.

Uses and Disclosures for Treatment, Payment and Health Care Operations.  Pharmacy and its respective business associates may use or disclose your PHI for the purposes of treatment, payment and health care operations, described in more detail below, without obtaining your consent, opportunity to agree or object, or specific written permission from you, known as an “authorization” under the HIPAA Privacy Rule.

For Treatment.  Pharmacy may use and disclose PHI in the course of treating Pharmacy patients. For example, PHI obtained by the pharmacist will be used to dispense prescription medications to you. We may disclose your information to other health care providers who are treating you through prescriptions, lab work, or individual healthcare specific documentation. We will document in your record information related to the medications dispensed to you and services provided to you.

For Payment.  Pharmacy may use and disclose PHI in order to bill and collect payment for the health care services provided to you. For example, we will disclose PHI to your health plan or pharmacy benefit manager to determine whether your prescription will be covered and the amount of your co-payment responsibility. We will disclose PHI to bill your health plan for the costs of prescription medications dispensed to you. The information on the bill may include information that identifies you, as well as the prescription medications you are taking.

For Health Care Operations.  Pharmacy may use and disclose PHI as part of its general business operations as a pharmacy. For example, we may use or disclose PHI for purposes of the evaluation of the treatment and services you receive and the performance of our staff in caring for you; for obtaining legal, accounting, auditing and other services; and for general business management and administration.

Other Uses and Disclosures For Which Consent, Authorization, or Opportunity to Object is Not Required.  In addition to using or disclosing PHI for treatment, payment and health care operations, Pharmacy may use and disclose PHI without your consent, written authorization, or opportunity to object in certain other circumstances summarized in the following situations:

As Required by Law, For Law Enforcement, and in Judicial or Administrative Proceedings.  Pharmacy may use and disclose PHI when required to do so by applicable law. Pharmacy also may disclose PHI when ordered to do so in a judicial or administrative proceeding; in response to a subpoena or other lawful process in a judicial or administrative proceeding; in response to a warrant or summons issued by a judicial officer or a grand jury subpoena; in response to a request by an administrative agency; to identify or locate a suspect, fugitive, material witness, or missing person; when dealing with gunshot and other wounds; about criminal conduct; to report a crime, the location of the crime or victims, or the identity, description, or location of a person who committed a crime; or for other law enforcement purposes.

For Public Health Activities and Public Health Risks. Pharmacy may disclose PHI to government officials in charge of collecting information about births and deaths, preventing and controlling disease, reports of child abuse or neglect and of other victims of abuse, neglect, or domestic violence; to notify a person who may have been exposed to a communicable disease or may be at risk of contracting or spreading a disease or condition; and to report defects or problems in food, drugs or other products to persons subject to regulation by the U.S. Food and Drug Administration (“FDA”).

For Health Oversight Activities.  Pharmacy may disclose PHI to the government for oversight activities authorized by law, such as audits, investigations, inspections, licensure or disciplinary actions, and other proceedings or activities necessary for monitoring the health care system, government programs, and compliance with civil rights laws.

Coroners, Medical Examiners, and Funeral Directors.  Pharmacy may disclose PHI to coroners, medical examiners, and funeral directors for the purpose of identifying a decedent, determining a cause of death, or otherwise as necessary to enable these parties to carry out their duties consistent with applicable law.

Organ, Eye, and Tissue Donation.  Pharmacy may release PHI to organ procurement organizations to facilitate donation and transplantation.

Research.  Pharmacy may use and disclose PHI for medical research.

To Avoid a Serious Threat to Health or Safety.  Pharmacy may use and disclose PHI, to law enforcement personnel or other appropriate persons, to prevent or lessen a serious threat to the health or safety of a person or the public.

Specialized Government Functions.  Pharmacy may use and disclose PHI of military personnel and veterans under certain circumstances. Pharmacy may also disclose PHI to authorized federal officials for intelligence, counterintelligence, and other national security activities, and for the provision of protective services to the President or other authorized persons or foreign heads of state or to conduct special investigations.

Workers’ Compensation.  Pharmacy may disclose PHI to comply with workers’ compensation or other similar laws. These programs provide benefits for work-related injuries or illnesses.

Appointment Reminders and Health-related Benefits and Services.  Pharmacy may use and disclose your PHI to contact you and remind you of an appointment at Pharmacy, or of the need to refill a prescription, or to inform you of treatment alternatives or other health-related benefits and services that may be of interest to you, such as disease management programs.

Disclosures to You or for HIPAA Compliance Investigations.  Pharmacy may disclose your PHI to you or to your personal representative, and is required to do so in certain circumstances described below in connection with your rights of access to your PHI and to an accounting of certain disclosures of your PHI. Pharmacy must disclose your PHI to the Secretary of the United States Department of Health and Human Services (the “Secretary”) when requested by the Secretary in order to investigate Pharmacy’s compliance with the HIPAA Privacy Rule.

Disclosures to Individuals Involved in Your Health Care or Payment for Your Health Care.  Unless you object, Pharmacy may disclose your PHI to a family member, other relative, friend, or other person you identify as involved in your health care or payment for your health care. Pharmacy may also notify those people about your location or condition. In some circumstances, Pharmacy may make the disclosures identified in this paragraph without first giving you an opportunity to agree or object, such as when your family member comes to the Pharmacy to pick up your filled prescription.

Personal Representatives.  You may exercise your rights through a personal representative. Your personal representative may be required to produce evidence of his/her authority to act on your behalf before that person will be given access to your PHI or allowed to take any action for you. Pharmacy retains discretion to deny access to your PHI to a personal representative to provide protection to those vulnerable people who depend on others to exercise their rights under these rules and who may be subject to abuse or neglect.

Uses and Disclosures of PHI For Which Authorization is Required.  Most uses and disclosures of psychotherapy notes, uses and disclosures of protected health information for marketing purposes, disclosures that would constitute a sale of PHI and other types of uses and disclosures of your PHI that do not fall within the categories generally described above will be made only with your written authorization, which you may revoke in writing at any time. Upon receipt of the written revocation of authorization, Pharmacy will stop using or disclosing your PHI, except to the extent necessary because we have already taken action in reliance on the authorization.

Regulatory Requirements.  Pharmacy is required by law to maintain the privacy of your PHI, to provide individuals with notice of its legal duties and privacy practices with respect to PHI, to notify affected individuals following a breach of unsecured PHI, and to abide by the terms described in this Notice. Pharmacy reserves the right to change the terms of this Notice and its privacy policies, and to make the new terms applicable to all of the PHI it maintains. When Pharmacy makes an important change to its privacy policies, it will promptly revise this Notice and post a new Notice.

Minimum Necessary Standard.  When using, disclosing or requesting PHI, Pharmacy will make reasonable efforts not to use, disclose or request more than the minimum amount of PHI necessary to accomplish the intended purpose of the use, disclosure or request, taking into consideration practical and technological limitations. However, the minimum necessary standard will not apply in certain circumstances such as: (i) disclosures to or requests by a health care provider for treatment; (ii) uses or disclosures made to you or pursuant to your authorization; (iii) disclosures for compliance to the Secretary of the U.S. Department of Health and Human Services; (iv) uses or disclosures that are required by law or for compliance with legal regulations.

You have the following rights regarding your PHI:

For health care items or services that you pay for out of pocket in full, you may restrict certain disclosures to a health plan, except when that disclosure is required by law.

For health care items or services that you do not pay for out of pocket in full, you may request that Pharmacy restrict the use and disclosure of the related PHI. Your requests must be made in writing and sent to the Health Privacy Office Pathstone Health Services, 8928 Prominence Parkway, #200 Jacksonville, FL 32256. However, Pharmacy is not required to agree to these restrictions you request, but Pharmacy will be bound by the restrictions to which it agrees, except in emergency situations.

You have the right to request that communications of PHI to you from Pharmacy be made by particular means or at particular locations. For instance, you might request that communications be made at your work address, or by e-mail rather than regular mail. Your requests must be made in writing and sent to the Health Privacy Office Pathstone Health Services, 8928 Prominence Parkway, #200 Jacksonville, FL 32256. Pharmacy will accommodate your reasonable requests without requiring you to provide a reason for your request.

Generally, you have the right to inspect and copy your PHI that Pharmacy maintains, provided that you make your request in writing to the Health Privacy Office, Pathstone Health Services, 8928 Prominence Parkway, #200 Jacksonville, FL 32256. Pharmacy may deny your request to inspect and copy in certain circumstances. If you request copies of your PHI or agree to a summary of your PHI, Pharmacy may impose a reasonable fee to cover copying, postage, and related costs. If Pharmacy denies access to your PHI, it will explain the basis for denial and whether or not you have an opportunity to have your request and the denial reviewed.

If you believe that your PHI maintained by Pharmacy contains an error or needs to be updated, you have the right to request that Pharmacy correct or supplement your PHI. Your request must be made in writing to the Health Privacy Office Pathstone Health Services, 8928 Prominence Parkway, #200 Jacksonville, FL 32256, and it must explain why you are requesting an amendment to your PHI. If your request is denied, in whole or in part, Pharmacy will provide you a written denial that explains the reason for the denial and your rights to: (i) file a statement disagreeing with the denial; (ii) if you do not file a statement of disagreement, submit a request that any future disclosures of the relevant PHI be made with a copy of your request and Pharmacy’s denial attached; and (iii) complain about the denial.

You generally have the right to request and receive a list of the disclosures of your PHI Pharmacy has made at any time during the six (6) years prior to the date of your request (but not before September 23, 2007). The list will not include disclosures for which you have provided a written authorization, and does not include certain uses and disclosures to which this Notice already applies, such as those: (i) for treatment, payment, and health care operations; (ii) made to you; (iii) to persons involved in your health care; (iv) for national security or intelligence purposes; or (v) to correctional institutions or law enforcement officials. You should submit any such request to the Health Privacy Office Pathstone Health Services, 58928 Prominence Parkway, #200 Jacksonville, FL 32256. Pharmacy will provide the list to you at no charge, but if you make more than one request in a year you will be charged a fee for each additional request.

You have the right to receive a paper copy of this notice upon request, even if you have agreed to receive this notice electronically. You can receive a copy of this notice at any of the following Web site: www.pathstonehealth.com. To obtain a paper copy of this notice, please contact the Health Privacy Office Pathstone Health Services,8928 Prominence Parkway, #200 Jacksonville, FL 32256.

You may complain to Pharmacy if you believe your privacy rights with respect to your PHI have been violated, by contacting the Health Privacy Office Pathstone Health Services, 8928 Prominence Parkway, #200 Jacksonville, FL 32256 and submitting a written complaint. Pharmacy will not penalize you or retaliate against you for filing a complaint regarding Pharmacy’s privacy practices. You also have the right to file a complaint with the Secretary of the U.S. Department of Health and Human Services, Hubert H. Humphrey Building, 200 Independence Avenue S.W., Washington, D.C. 20201.

If you have any questions about this notice, please contact the Health Privacy Office, Pathstone Health Services, 8928 Prominence Parkway, #200 Jacksonville, FL 32256, or you may call 866-946-6349.

Effective Date: September 23, 2013

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PATHSTONE HEALTH SERVICES PHARMACY 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.

This Addendum describes State laws governing the Pharmacy's use of your health information. The Pharmacy will comply with the applicable State law instead of the HIPAA Privacy Rule to the extent the State law provides greater privacy protection, or gives you more rights regarding your health information, than does the HIPAA Privacy Rule.

ALL STATES

The Pharmacy will not disclose the following categories of individual identifiable health information except in situations where the subject of the information has provided us with a written authorization allowing the release, or where we are permitted or required by state or federal law to make the disclosure. These categories include HIV/AIDS, mental health, communicable disease, alcohol and substance abuse, genetic information, information pertaining to minors and reproductive rights.

ALABAMA

1. Disclosure.  The Pharmacy will not disclose your professional records to anyone without your authorization, except where it is in your best interest or where the law requires the disclosure.

2. Medicaid.  For Medicaid recipients, unless approved by Alabama Medicaid office, the Pharmacy will disclose information pertaining to your treatment (including billing statements and itemized bills) only to:

  • the Medicaid Fiscal Agent;
  • the Social Security Administration;
  • the Alabama Vocational Rehabilitation Agency;
  • the Alabama Medicaid Agency;
  • insurance companies requesting information about a Medicaid claim filed by the provider, an insurance application, payment of life insurance benefits, or payment of a loan; or
  • other providers who need the information for treatment of a patient.

FLORIDA

1. Disclosure.  The Pharmacy will not disclose your pharmacy records without your written authorization, except to:

  • you;
  • your legal representative;
  • the Department of Health pursuant to existing law;
  • in the event that you are incapacitated or unable to request your records, your spouse; and
  • in any civil or criminal proceeding, upon the issuance of a subpoena from a court of competent jurisdiction and proper notice to you or your legal representative, by the party seeking the records.

GEORGIA

1. Disclosure.  Unless authorized by you, we will not disclose your confidential information to anyone other than you or your authorized representative, except to the following persons or entities:

  • the prescriber, or other licensed health care practitioners caring for you;
  • another licensed pharmacist for purposes of transferring a prescription or as part of a patient's drug utilization review, or other patient counseling requirements;
  • the Board of Pharmacy, or its representative; or
  • any law enforcement personnel duly authorized to receive such information.

2. Lawful Process.  The Pharmacy may also disclose your confidential information without your consent pursuant to a subpoena issued and signed by an authorized government official or a court order issued and signed by a judge of an appropriate court.

3. HIV/AIDS.  The Pharmacy will not disclose AIDS confidential information, except in situations where the subject of the information has provided us with a written authorization allowing the release or where we are authorized or required by state or federal law to make the disclosure.

LOUISIANA

No supplemental State law material. Please refer to the Notice of Privacy Practices.

MISSISSIPPI

No supplemental State law material. Please refer to the Notice of Privacy Practices.

NORTH CAROLINA

1. Disclosure.  We will not disclose or provide a copy of your prescription orders on file except to:

  • you;
  • your parent or guardian or other person acting in loco parentis if you are a minor and have not lawfully consented to the treatment of the condition for which the prescription was issued;
  • the licensed practitioner who issued the prescription or who is treating you;
  • a pharmacist who is providing pharmacy services to you;
  • anyone who presents a written authorization for the release of pharmacy information signed by you or your legal representative;
  • any person authorized by subpoena, court order or statute;
  • any firm, company, association, partnership, business trust, or corporation who by law or by contract is responsible for providing or paying for medical care for you;
  • any member or designated employee of the Board of Pharmacy;
  • the executor, administrator or spouse of a deceased patient;
  • Board-approved researchers, if there are adequate safeguards to protect the confidential information; and
  • the person who owns the pharmacy or his licensed agent.

2. Lawful Process.  The Pharmacy may also disclose your confidential information without your consent pursuant to a subpoena issued and signed by an authorized government official or a court order issued and signed by a judge of an appropriate court.

3. HIV/AIDS.  The Pharmacy will not disclose AIDS confidential information, except in situations where the subject of the information has provided us with a written authorization allowing the release or where we are authorized or required by state or federal law to make the disclosure.4.
   Communicable diseases.  The Pharmacy will not disclose communicable disease-related information about an individual, except in situations where the subject of the information
   has provided us with a written authorization allowing the release or where we are authorized or required by state or federal law to make the disclosure.

SOUTH CAROLINA

Disclosure.  We will not disclose your prescription drug information without first obtaining you consent, except in the following circumstances:

  • the lawful transmission of a prescription drug order in accordance with state and federal laws pertaining to the practice of pharmacy;
  • communications among licensed practitioners, pharmacists and other health care professionals who are providing or have provided services to you;
  • information gained as a result of a person requesting informational material from a prescription drug or device manufacturer or vendor;
  • information necessary to effect the recall of a defective drug or device or protect the health and welfare of an individual or the public; representative of the agency requesting the information.
  • information whereby the release is mandated by other state or federal laws, court order, or subpoena or regulations (e.g., accreditation or licensure requirements);
  • information necessary to adjudicate or process payment claims for health care, if the recipient makes no further use or disclosure of the information;
  • information voluntarily disclosed by you to entities outside of the provider-patient relationship;
  • information used in clinical research monitored by an institutional review board, with your written authorization;
  • information which does not identify you by name, or that is encoded in a manner that identifying you by name or address is generally not obtainable, and that is used for epidemiological studies, research, statistical analysis, medical outcomes, or pharmacoeconomic research;
  • information transferred in connection with the sale of a business;
  • information necessary to disclose to third parties in order to perform quality assurance programs, medical records review, internal audits, medical records maintenance, or similar programs, if the third party makes no other use or further disclosure of the information;
  • information that may be revealed to a party who obtains a dispensed prescription on your behalf; or
  • information necessary in order for a health plan licensed by the South Carolina Department of Insurance to perform case management, utilization management, and disease management for individuals enrolled in that health plan, if the third part makes no other use or disclosure of the information.

We will not disclose your information or the nature of professional pharmacy services rendered to you, without your express consent or the order or direction of a court, except to:

  • you, or your agent, or another pharmacist acting on your behalf;
  • the practitioner who issued the prescription drug order;
  • Certified/licensed health care personnel who are responsible for your care;
  • an inspector, agent or investigator from the Board of Pharmacy or any federal, state, county, or municipal officer whose duty is to enforce the laws of South Carolina or the United States relating to drugs or devices and who is engaged in a specific investigation involving a designated person or drug; and
  • a government agency charged with the responsibility of providing medical care for you upon written request by an authorized representative of the agency requesting the information.

2. Lawful Process.  The Pharmacy may also disclose your confidential information without your consent pursuant to a subpoena issued and signed by an authorized government official or a court order issued and signed by a judge of an appropriate court.

TENNESSEE

Disclosure.  We will not disclose your name and address or other identifying information, except to:

  • a health or government authority pursuant to any reporting required by law;
  • an interested third-party Payer for the purpose of utilization review, case management, peer reviews, or other administrative functions; or
  • in response to a subpoena issued by a court of competent jurisdiction.

We will obtain your authorization before we disclose your patient records for any reason, except where:

  • the disclosure is in your best interest;
  • the law requires the disclosure; or
  • the disclosure is to an authorized prescriber or to communicate a prescription order where necessary to:
    1. carry out prospective drug use review as required by law;
    2. assist prescribers in obtaining a comprehensive drug history on you; or
    3. prevent abuse or misuse of a drug or device and the diversion of controlled substances.

Sale of Information:  We will not sell your name and address or other identifying information for any purpose.

2. Lawful Process.  The Pharmacy may also disclose your confidential information without your consent pursuant to a subpoena issued and signed by an authorized government official or a court order issued and signed by a judge of an appropriate court.