NOTICE OF PRIVACY PRACTICES
THIS PAGE 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 part of the federal Health Insurance Portability and Accountability Act of 1996, known as HIPAA, the pharmacy has created this Notice of Privacy Practices (Notice). This Notice describes the pharmacy’s privacy 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 relates to your past and present physical and mental health care services. The HIPAA regulations require that the pharmacy protect the privacy of your PHI that the pharmacy has received or created.
This pharmacy will abide by the terms presented within this Notice. For any uses or disclosures that are not listed below, the pharmacy will obtain a written authorization from you for that use or disclosure, which you will have the right to revoke at any time, as explained in more detail below. The pharmacy reserves the right to change the pharmacy’s privacy practices and this Notice. Revisions to the Notice will be posted in the pharmacy and upon your request, provided to you in a paper format.
HOW THE PHARMACY MAY USE AND DISCLOSE YOUR PHI
The following is an accounting of the ways that the pharmacy 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 pharmacy 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 pharmacy may use the minimum necessary amount of your PHI to conduct quality assessments, improvement activities, and evaluate the pharmacy workforce.
The following is an accounting of additional ways in which the pharmacy 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 pharmacy; however, we are required by law to notify you of them as a health care provider.
Uses and disclosures as required by law: The pharmacy is required to use or disclose PHI about you as required and as limited by law.
Uses and disclosure for Public Health Activities: The pharmacy may use or disclose PHI about you to a public health authority that is authorized by law to collect for the purpose of 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 pharmacy may use or disclose PHI about you to a government authority if it is reasonably believed you are a victim of abuse, neglect or domestic violence.
Uses and disclosures for health oversight activities: The pharmacy 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 pharmacy may disclose PHI about you in the course of any judicial or administrative proceedings, provided that proper documentation is presented to the pharmacy.
Disclosures for law enforcement purposes: The pharmacy 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 about the deceased: The pharmacy may disclose PHI about a deceased, or prior to, and in reasonable anticipation of an individual’s death, to coroners, medical examiners, and funeral directors.
Uses and disclosures for cadaveric organ, eye or tissue donation purposes: The pharmacy may use and disclose PHI for the purpose of procurement, banking, or transplantation of cadaveric organs, eyes, or tissues for donation purposes.
Uses and disclosures for research purposes: The pharmacy may use and disclose PHI about you for research purposes with a valid waiver of authorization approved by an institutional review board or a privacy board. Otherwise, the pharmacy 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 pharmacy may use or disclose PHI about you, if it 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 pharmacy 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 pharmacy 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 pharmacy 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 pharmacy may disclose PHI about you to the pharmacy’s business associates for services that they may provide to or for the pharmacy to assist the pharmacy to provide quality health care. To ensure the privacy of your PHI, we require all business associates to apply appropriate safeguards to any PHI they receive or create.
OTHER USES AND DISCLOSURES
The pharmacy may contact you for the following purposes:
Refill reminders: The pharmacy may contact you to remind you of your prescription upon such time they are ready to be refilled.
Information about treatment alternatives: The pharmacy may contact you to notify you of alternative treatments and/or products.
Health related benefits or services: The pharmacy may use your PHI to notify you of benefits and services the pharmacy provides.
FOR ALL OTHER USES AND DISCLOSURES
The pharmacy will obtain a written authorization from you for all other uses and disclosures of PHI, and the pharmacy 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 Compliance Officer, Vicki Jung 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 pharmacy’s uses and disclosures of your PHI; however, the pharmacy 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 pharmacy and return the completed form to the pharmacy.
The right to have your PHI communicated to you by alternate means or locations: You have the right to request that the pharmacy communicate confidentially with you using an address or phone number other than your residence. However, state and federal laws require the pharmacy to have an accurate address and home phone number in case of emergencies. The pharmacy will consider all reasonable requests. If you wish to request a change in your communicating address and/or phone number, please obtain a form, Request for Alternative Arrangements for Confidential Communication, from the pharmacy and return the completed form to the pharmacy.
The right to inspect and/or obtain a copy your PHI: You have the right to request access and/or obtain a copy of your PHI that is contained in the pharmacy for the duration the pharmacy 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 pharmacy and return the completed form to the pharmacy. 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 pharmacy maintains about you, if you feel that the PHI the pharmacy 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 States 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 pharmacy and return the completed form to the pharmacy.
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 pharmacy. If you wish to receive an accounting of disclosures of your PHI, please obtain a form, Request for Accounting of Disclosures, from the pharmacy and return the completed form to the pharmacy. 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 Pharmacy’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 pharmacy workforce member and they will provide you with a copy.
PATIENT RIGHTS AND RESPONSIBILITIES
Patients receiving products and services from Chemistry Rx Pharmacy, a Compound and Specialty Pharmacy, have the following rights:
- To select those who provide your health care services.
- To receive the appropriate or prescribed service in a professional manner without discrimination relative to your age, sex, race, religion, ethnic origin, sexual preference or physical or mental handicap.
- To be promptly informed if the prescribed care or services are not within the scope of service, mission, or philosophy of Chemistry Rx, and therefore be provided with transfer assistance to an appropriate care or service organization.
- To be dealt with and treated with friendliness, courtesy, and respect by each and every individual representing Chemistry Rx who comes in contact with you during the course of your therapy insuring freedom from mental, physical, sexual, and verbal abuse, neglect, and exploitation.
- To have your privacy and property respected at all times.
- To assist in the development and planning of your health care program that is designed to satisfy in the best possible manner your current needs as they have been presented.
- To be provided with adequate information from which you can give your informed consent for the commencement of service, the continuation of service, the transfer of service to another health care provider, or termination of service.
- To express concerns or grievances or recommend modification to your Chemistry Rx product or services provider without fear of discrimination or reprisal.
- To identify the staff member of Chemistry Rx and their job title, and to speak with a supervisor of the staff member if requested.
- To request and receive complete and up-to-date information relative to your condition, treatment, alternative treatments, risks of treatment within the physician’s legal responsibilities of medical disclosure.
- To receive care and services within the scope of your health care plan, promptly and professionally, while being fully informed of Chemistry Rx policies, procedures, and charges relative to your care and who is providing your care.
- To refuse care within the boundaries set by law, and receive professional information relative to the ramifications or consequences that will or may result due to such refusal.
- To request and receive the opportunity to examine or review your medical records.
- To request and receive data regarding services or costs thereof privately and with confidentiality.
- To expect that information received by Chemistry Rx will be kept confidential and will not be released without written consent of you or your responsible party.
- To be involved, as appropriate, in discussions and resolutions of conflicts and ethical issues related to your care.
- To be informed of any experimental or investigational studies that are involved in your care, and be provided the right to refuse any such activity.
- To be informed of any unanticipated or negative outcomes of care, treatment and services that relate to a serious sentinel event during the course of care.
- The patient has the right to access, request amendments to, and receive an accounting of disclosures regarding his or her own health information as permitted under applicable law.
Patients receiving products and services from Chemistry Rx Pharmacy, a Compound and Specialty Pharmacy, have the following responsibilities:
- To provide accurate information concerning your present health status, current medications, allergies, and insurance coverage to Chemistry Rx as appropriate to your care or service.
- To inform a staff member, if applicable, of your health history, including past hospitalizations, illnesses, injuries, etc.
- To involve yourself as needed and as able in developing, carrying out, and modifying your plan of care plan, if applicable.
- To evaluate your home environment and make necessary corrections to plan for safe medication handling and storage.
- To request additional assistance or information on any phase of your health care plan that you do not fully understand.
- To notify your physician and Chemistry Rx when you feel ill, or encounter any unusual physical or mental stress or sensations, which may be as a result of the care, products or services being provided.
- To notify Chemistry Rx when you will not be home at the time of a scheduled delivery or visit, if applicable.
- To notify Chemistry Rx prior to changing your address or telephone number.
- To notify Chemistry Rx when you encounter any problem with equipment or service.
- To notify Chemistry Rx if you are hospitalized or if your physician modifies or stops your service or care, if applicable.
- To ask questions related to the care and services provided to you by Chemistry Rx.
- To follow instructions given to you by Chemistry Rx for the care and services being provided, if applicable.
- To meet financial commitments resulting from the care and services provided by Chemistry Rx.
- To treat Chemistry Rx representatives with respect in the care and services being provided.
- To provide information requested from Chemistry Rx needed to provide care.
- To follow Chemistry Rx rules and regulations as they pertain to the products and services provided by Chemistry Rx.
- To adhere to the above mentioned responsibilities and accept the consequences involved should these responsibilities not be met.
As a matter of company policy and in compliance with Pennsylvania Pharmacy Law, we do not accept returns of medications once it has left the premises of the pharmacy. Medications that have been delivered or have been attempted to be delivered cannot be returned and reused.
No Charge Backs/ Reversals/ Cash Refunds/ Cash Credits: No charge backs or reversals of payment and no cash refunds or cash credits are available.
Pick-Up: If you agree to pick-up your medication, any payment made to your credit/debit card in advance is in agreement that you will pick-up your medication. We cannot return compounded medications to stock and do not offer refunds/chargebacks/reversals to patients who fail to pick-up their medication.
DUE TO THE NATURE OF OUR PRODUCTS NO RETURNS ARE AVAILABLE.
Concerns and Complaints
If you have any concerns or complaints, please call 855-790-0100 or email us at firstname.lastname@example.org.
To Report a Problem
Complaints: If you believe your privacy rights have been violated, you can file a complaint with the Chemistry Rx Privacy Officer or with the Secretary of the United States Department of Health and Human Services. All complaints must be submitted in writing. You will not be penalized or otherwise retaliated against in any way for filing a complaint.
A prescription from a licensed practitioner is required for compounded medications.
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