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.
Pathmark Pharmacy ("The
Pharmacy") is required by law to maintain the privacy
of Protected Health Information ("PHI") and to provide
individuals with notice of our legal duties and privacy
practices with respect to PHI. PHI is 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 Notice of Privacy
Practices ("Notice") describes how we may use and disclose
PHI 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 any revised Notice to you.
Your Health Information
Rights
You have the following
rights with respect to PHI about 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 Pathmark
Privacy Officer, c/o General Counsel’s Office, 200 Milik
Street, Carteret NJ 07008.
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 Pathmark Privacy Officer, c/o General Counsel’s
Office, 200 Milik Street, Carteret NJ 07008. 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 Pathmark Privacy
Officer, c/o General Counsel’s Office, 200 Milik Street,
Carteret NJ 07008. We may charge you a fee for the costs
of copying, mailing and supplies that are necessary
to fulfill 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 an 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 an amendment for as long as
we maintain the PHI. To request an amendment, you must
send a written request to Pathmark Privacy Officer,
c/o General Counsel’s Office, 200 Milik Street, Carteret
NJ 07008. 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 may give a rebuttal to your
statement.
Receive an accounting
of disclosures of PHI. You have the right to receive
an accounting of the disclosures we have made of PHI
about you after April 14, 2003 for most purposes other
than treatment, payment, or health care operations.
The accounting will exclude certain disclosures, such
as disclosures made directly to you, disclosures you
authorize, disclosures to friends or family members
involved in your care, and disclosures for notification
purposes. The right to receive an accounting is subject
to certain other exceptions, restrictions, and limitations.
To request an accounting, you must submit a request
in writing to Pathmark Privacy Officer, c/o General
Counsel’s Office, 200 Milik Street, Carteret NJ 07008.
Your request must specify the time period, but may not
be longer than six years. The first accounting you request
within a 12 month period will be provided free of charge,
but you may be charged for the cost of providing additional
accountings. We will notify you of the cost involved
and you may choose to withdraw or modify your request
at that time.
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 a request in writing
to Pathmark Privacy Officer, c/o General Counsel’s Office,
200 Milik Street, Carteret NJ 07008. Your request must
state how or where you would like to be contacted. We
will accommodate all reasonable requests.
Examples of How We May
Use and Disclose PHI
Subject to applicable state
law, a description of which is appended to this Notice,
the following are descriptions and examples of ways
we use and disclose PHI:
We will use PHI for
treatment. For 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 may contact you
or your doctor via mail or phone about your prescription,
and we may contact you to provide refill reminders or
information about treatment alternatives or other health-related
benefits and services that may be of interest to you.
We will use PHI for
payment For example, we will contact your insurer
or pharmacy benefit manager to determine whether it
will pay for your prescription and the amount of your
copayment. We will bill you or a third-party payor 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. In addition, benefit administrators
or their agents may perform payment audits relevant
to delivery of services provided.
We will use PHI for
health care operations. For example, the Pharmacy
may use information in your health record to monitor
the delivery of quality 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.
Subject to applicable state
law, a description of which is appended to this Notice,
we also are permitted or required to use or disclose
PHI for the following purposes; however, some of these
disclosures may never occur at our pharmacies:
Business associates:
There are some services provided by us through contracts
with business associates. When these services are contracted
for, we may disclose PHI about you to our business associate
so that they can perform the job we have asked them
to do. To protect PHI about you, we require the business
associate to appropriately safeguard the PHI.
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 persons under
the jurisdiction of the FDA, 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 as authorized by and as
necessary to comply with laws relating to worker's compensation
or 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
or other legal process.
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
or peer group for activities authorized by law. These
oversight activities include abuse detection, audits,
investigations, and inspections, as necessary for our
licensure and for the government to monitor the health
care system, government programs, compliance with regulatory
guidelines and 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.
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 examiners 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.
Fundraising: We
may contact you as part of a fundraising effort.
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 your general condition.
Correctional institution:
If you are or become an inmate of a correctional institution,
we may disclose PHI to the institution or its agents
when necessary for your health or the health and safety
of others.
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 the health and safety of
the public or another person.
Military and veterans:
If you are a member of the armed forces, we may release
PHI about you as required by military command authorities.
We may also release PHI about foreign military personnel
to the appropriate military authority.
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.
Protective services
for the President and others: We may disclose PHI
about you to authorized federal official so they may
provide protection to the President, other authorized
persons or foreign heads of state or conduct special
investigations.
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 it is necessary
and will not be used against you.
Other Uses and Disclosures
of PHI
The Pharmacy will obtain
your written authorization before using or disclosing
PHI about
you for purposes other
than those provided for above or as otherwise permitted
or required by law. You may revoke an 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.
Minors
If you are a minor who
has lawfully provided consent for treatment and you
would like the Pharmacy, to the extent permitted by
your state’s laws, to treat you as an adult for
purposes of access to and disclosure of records related
to such treatment, please notify the pharmacist.
For More Information
or to Report a Problem
If you have questions or
would like additional information about the Pharmacy's
privacy practices, you may contact Pathmark Privacy
Officer in writing at 200 Milik Street, Carteret NJ
07008. If you believe your privacy rights have been
violated, you can file a complaint with the Pathmark
Privacy Officer Attention General Counsel or with the
Secretary of Health and Human Services. There will be
no retaliation for filing a complaint.
State
Law Addendum
The following requirements
modify the listed "Examples of How We May Use
and Disclose PHI" in the states indicated,
except as otherwise permitted or required by law:
NEW YORK—We will
not access a common electronic file or database used
to maintain required personally identifiable dispensing
information except upon your, or your agent’s, express
request.
PENNSYLVANIA—We
will not disclose any HIV-related information, except
in situations where the subject of the information has
provided us with a written consent allowing the release
or where we are authorized or required by state or federal
law to make the disclosure.
Effective Date March 2003
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