Notice of Privacy Practices

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
.

Pratt Medical Arts Pharmacy will ask you to sign an Acknowledgement that you have received this Notice of Privacy
Practices (Notice). This Notice describes how Pratt Medical Arts Pharmacy may use and disclose your protected health
information in accordance with the HIPAA Privacy Rule. It also describes your rights and Pratt Medical Arts Pharmacy’s
duties with respect to protected health information about you.

Section A: Uses and Disclosures of Protected Health Information

1. Treatment, Payment and Health Care Operations

a. We will use your health information to provide treatment. This may involve receiving or sharing
information with other health care providers such as your physician. This information may be written,
verbal, electronic or via facsimile. This will include receiving prescription orders so that we may
dispense prescription medications. We may also share information with other health care providers
who are treating you to coordinate the different things you need, such as medications, lab work or other
appointments. We may also contact you to provide treatment-related services, such as refill reminders,
treatment alternatives and other health related services that may be of benefit to you.

b. We will use your health information to obtain payment. This will include sending claims for payment to
your insurance or third-party payer. It may also include providing health information to the payer to
resolve issues of claim coverage.

c. We will use your health information for our health care operations necessary to run the pharmacy. This
may include monitoring the quality of care that our employees provide to you and for training purposes.

2. Permitted or Required Uses and Disclosures

a. Our pharmacists, using their professional judgment may disclose your protected health information to a
family member, other relative, close personal friend or other person you identify as being involved in
your health care. This includes allowing such persons to pick up filled prescriptions, medical supplies or
medical records on your behalf.

b. We also have contracts with entities called Business Associates that perform some services for us that
require access to your protected health information. Examples may include companies that route claims
to your insurance company or that reconcile the payments we receive from your insurance. We require
our Business Associates to safeguard any protected health information appropriately.

c. Under certain circumstances Pratt Medical Arts Pharmacy may be required to disclose health
information as required or permitted by federal or state laws. These include, but are not limited to:

i. To the Food and Drug Administration (FDA) relating to adverse events regarding drugs, foods,
supplements and other health products or for post-marketing surveillance to enable product
recalls, repairs or replacement.

ii. To public health or legal authorities charged with preventing or controlling disease, injury or
disability.

iii. To law enforcement agencies as required by law or in response to a valid subpoena or other
legal process.

iv. To health oversight agencies (e.g., licensing boards) for activities authorized by law such as
audits, investigations and inspections necessary for Pratt Medical Arts Pharmacy’s licensure and
for monitoring of health care systems.

v. In response to a court order, administrative order, subpoena, discovery request or other lawful
process by another person involved in a dispute involving a patient, but only if efforts have been
made to tell the patient about the request or to obtain an order protecting the requested health
information.

vi. As authorized by and as necessary to comply with laws relating to worker’s compensation or
similar programs established by the law.

vii. Whenever required to do so by law.
viii. To a Coroner or Medical Examiner when necessary. Examples include: identifying a deceased
person or to determine a cause of death.

ix. To Funeral Directors to carry out their duties

x. To organ procurement organizations or other entities engaged in procurement, banking or
transplantation of organs for the purpose of tissue donation and transplant.

xi. To notify or assist in notifying a family member, personal representative or another person
responsible for the patient’s care of the patient’s location or general condition.

xii. To a correctional institution or its agents if a patient is or becomes an inmate of such an
institution when necessary for the patient’s health or the health and safety of others.

xiii. When necessary to prevent a serious threat to the patient’s health and safety or the health and
safety of the public or another person.

xiv. As required by military command authorities when the patient is a member of the armed forces
and to appropriate military authority about foreign military personnel.

xv. To authorized officials for intelligence, counterintelligence and other national security activities
authorized by law.

xvi. To authorized federal officials so they may provide protection to the president, other authorized
persons or foreign heads of state or to conduct special investigations.

xvii. To a government authority, such as social service or protective services agency, if Pratt Medical
Arts Pharmacy reasonably believes the patient to be a victim of abuse, neglect or domestic
violence but only to the extent required by law, if the patient agrees to the disclosure or if the
disclosure is allowed by law and we believe it is necessary to prevent serious harm to the patient
or to 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 the patient.

3. Authorized Use and Disclosure

a. Use or disclosure other than those previously listed or as permitted or required by law, will not be made
unless we obtain your written Authorization in advance. You may revoke any such Authorization in
writing at any time. Upon receipt of a revocation, we will cease using or disclosing protected health
information about you unless we have already taken action based on your Authorization.

4. More Stringent Laws

a. Some states may have laws that are more stringent than HIPAA. Please refer to the end of the Notice
for the laws that may apply.

Section B: Patient’s Rights

1. Restriction Requests

a. You have a right to request a restriction be placed on the use and disclosure of your protected health
information for purposes of carrying out treatment, payment or health care operations. Restrictions
may include requests for not submitting claims to your insurance or third-party payer or limitations on
which persons may be considered personal representatives.

b. Pratt Medical Arts Pharmacy is not required to accept restrictions other than payment related uses not
required by law that have been paid in full by the individual or representative other than a health plan.

c. If we do agree to requested restrictions, they shall be binding until you request that they be terminated.

d. Requests for restrictions or termination of restrictions must be submitted in writing to the Privacy
Officer listed in Section D of this Notice.

2. Alternative Means of Communication

a. You have a right to receive confidential communications of protected health information by alternate
methods or at alternate locations upon reasonable request. Examples of alternatives may be sending
information to a phone or mailing address other than your home.

b. Pratt Medical Arts Pharmacy shall make reasonable accommodation to honor requests.

3. Requests must be submitted in writing to the Privacy Officer listed in Section D of this Notice.Access to Health
Information

a. You have a right to inspect and copy your protected health information. The designated record set will
usually include prescription and billing records. You have the right to request the protected health
information in the designated record set for as long as we maintain your records.

b. You have the right to request that your protected health information be provided to you in an electronic
format if available.

c. Requests must be submitted in writing to the Privacy Officer listed in Section D of this Notice.

d. Any costs or fees associated with copying, mailing or preparing the requested records will be charged
prior to granting your request.

e. Pratt Medical Arts Pharmacy may deny your request for records in limited circumstances. In case of
denial, you may request a review of the denial for most reasons. Requests for review of a denial must
also be submitted to the Privacy Officer listed in Section D of this Notice.

4. Amendments to Health Information

a. If you believe that your protected health information is incomplete or incorrect, you may request an
amendment to your records. You may request amendment to any records for as long as we maintain
your records.

b. Requests must be submitted in writing to the Privacy Officer listed in Section D of this Notice.

c. Requests must include a reason that supports the amendment to your health information.

d. Pratt Medical Arts Pharmacy may deny amendment requests in certain cases. In case of denial, you
have the right to submit a Statement of Disagreement. We have the right to provide a rebuttal to your
statement.

5. Accounting of Uses and Disclosures

a. You have the right to request an accounting of uses and disclosures that are not for treatment, payment
or health care operations. This accounting may include up to the six years prior to the date of request
and will not include an accounting of disclosures to yourself, your personal representatives or anything
authorized by you in writing. Other restrictions may apply as required in the Privacy Rule.

b. Requests must be submitted in writing to the Privacy Officer listed in Section D of this Notice.

c. The first accounting in any 12-month period will be provided to you at no cost. Any additional requests
within the same 12-month period will be charged a fee to cover the cost of providing the accounting.
This fee amount will be provided to you prior to completing the request. You may choose to withdraw
your request to avoid paying this fee.

6. Notice of Privacy Practices

a. You have a right to receive a paper copy of this Notice even if you previously agreed to receive a copy
electronically.

b. Please submit a request to the Privacy Officer listed in Section D of this Notice.

Section C: Pratt Medical Arts Pharmacy’s Duties

Pratt Medical Arts Pharmacy is required by law to maintain the privacy of protected health information, to provide
individuals with notice of its legal duties and privacy practices with respect to protected health information, and to
notify affected individuals following a breach of unsecured protected health information.
Pratt Medical Arts Pharmacy is required to abide by the terms of this Notice. We reserve the right to change the terms
of this Notice and to make the new notice provisions effective for all protected health information that we maintain. Any
such revised Notice will be made available upon request.

Section D: Contacting Us

1. Additional Questions, Submitting Requests or Complaints

a. If you have questions about this Notice or how Pratt Medical Arts Pharmacy uses and discloses your
protected health information please contact our Privacy Officer below.

b. You may obtain forms needed for request submission from our pharmacy or from our Privacy Officer.

c. If you believe your privacy rights have been violated you may file a complaint with our Privacy Officer or
with the Secretary of Health and Human Services. You will not be retaliated against for filing a
complaint.

2. Privacy Officer

Allison Morford PharmD
Pratt Medical Arts Pharmacy
420 Country Club Road
Pratt, KS 67124
620-672-7447

3. Secretary of Health and Human Services, Office for Civil Rights

a. For online complaint forms and contact information for the Regional OCR offices:
http://www.hhs.gov/ocr/privacy/index.html

b. Email: OCRComplaint@hhs.gov for assistance or questions about complaint forms

Section E: State Specific Requirements