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WELLPOINTE 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 NOTICE IS EFFECTIVE AS OF APRIL 14, 2003
The Pharmacy is required to
maintain the privacy of your Protected Health Information ("PHI") and to provide
you with a notice of our legal duties and privacy practices with respect to PHI.
PHI is information about you, including basic demographic 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 about you 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 a revised Notice to you.
Examples of How We May Use and
Disclose PHI:
The following categories
describe and provide examples of different ways that we use and disclose PHI
about you.
We will use PHI for treatment.
Example: Information obtained by the pharmacy 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 will use PHI for payment.
Example: We will
contact your insurer or pharmacy benefit manager to determine whether it will
pay for your prescription and the amount of your co-payment responsibility. 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.
We will use PHI for health care
operations. Example: The Pharmacy may use information in your health
record to monitor the performance of the pharmacists providing 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.
We are likely to use or disclose
PHI for the following purposes:
Business associates: There are
some services provided by us through contracts with business associates. An
example of this is the company that writes and maintains our prescription
processing software. 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 and bill you or your third-party payor for services rendered.
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.
Program Registrations: In order
for us to dispense or order certain medications, you may be required to register
with an outside company. Other medications may require you to submit blood work
prior to receiving your prescription.
Once you have enrolled or
submitted your blood work we may disclose information about you, your
enrollment, or your blood work to those outside companies necessary to continue
your treatment.
Personal communications: 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 may contact you to inform you about the status of your
prescription(s) whether they be ready for pick-up, on order, or delayed for any
reason. We may also contact you to follow up with the care you have received or
to offer to answer any questions you may have related to your treatment.
Food and Drug Administration
(FDA): We may disclose to the FDA or its agents 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.
Workers’ Compensation: We may
disclose PHI about you to the extent authorized by and to the extent necessary
to comply with laws relating to worker's compensation or other similar programs
established by law.
Other Health Care Providers: We
may disclose PHI about you for treatment or payment activities of another health
care provider. We may also disclose PHI about you to another health care
provider for the health care operation’s activities (quality assessments,
competence, and performance reviews as well as others) of that health care
provider providing they too have a relationship with you. We may also disclose
PHI about you to such a health care provider for the purpose of health care
fraud and abuse detection or compliance.
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.
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 for activities authorized by law. These oversight activities include
audits, investigations, and inspections, as necessary for our licensure and for
the government to monitor the health care system, government programs, and
compliance with 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.
We are permitted to use or
disclose PHI about you for the following purposes:
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
examiner.
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.
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 general condition.
Correctional institution: If you
are or become an inmate of a correctional institution, we may disclose to the
institution or its agents, PHI necessary for your health and 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
officials 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 this 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.
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, you may request one in person at
Wellpointe Pharmacy.
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 Wellpointe Pharmacy (address listed below). Forms for this
are available at Wellpointe Pharmacy. It is not necessary to use this form but
it may aid you in providing adequate information for us to process your request.
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 Wellpointe Pharmacy (address listed above). Forms for this are
available at Wellpointe Pharmacy. It is not necessary to use this form but it
may aid you in providing adequate information for us to process your request. We
may charge you a fee for the costs of copying, mailing, or other supplies that
are necessary to grant 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
Wellpointe Pharmacy(address listed below). Forms for this are available at
Wellpointe Pharmacy. It is not necessary to use this form but it may aid you in
providing adequate information for us to process your request. In addition, 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 you
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 disclosures we have made directly to you, 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 your request in writing to:
Wellpointe Pharmacy
1701 South Boulevard, suite 105
Rochester Hills, MI 48307
Forms for this are available at
Wellpointe Pharmacy. It is not necessary to use this form but it may aid you in
providing adequate information for us to process your request. 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 your request in writing to Wellpointe pharmacy (address
listed above). Forms for this are available at Wellpointe Pharmacy. It is not
necessary to use this form but it may aid you in providing adequate information
for us to process your request. Your request must state how or when you would
like to be contacted. We will accommodate all reasonable requests.
For More Information or to
Report a Problem
If you have questions or would
like additional information about Wellpointe Pharmacy’s privacy practices, you
may contact us at 1-248-852-9355 or send an e-mail to:
wellpointerx@sbcglobal.net
If you believe your privacy
rights have been violated, you can file a complaint with the Secretary of Health
and Human Services. There will be no retaliation for filing a complaint.
