WATKINS PHARMACY AND SURGICAL SUPPLY NOTICE OF PRIVACY PRACTICES Effective April 13, 2003 AS REQUIRED BY THE PRIVACY REGULATIONS PROMULGATED PURSUANT TO THE HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996 (HIPPA) THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. A OUR COMMITMENT TO YOUR PRIVACY Our organization is dedicated to maintaining the privacy of your identifiable health information. In conducting our business, we will create records regarding you and the treatment and services we provide to you. We are required by law to maintain the confidentiality of health information that identifies you. We are also required by law to provide you with this notice of our legal duties and privacy practices concerning your identifiable health information. By law, we must follow the terms of the notice of privacy practices that we have in effect at the time. To summarize, this notice provides you with the following important information: *how we may use and disclose your identifiable health information *your privacy rights in your identifiable health information, and *our obligations concerning the use and disclosure of your identifiable health information. THE TERMS OF THIS NOTICE APPLY TO ALL RECORDS CONTAINING YOUR IDENTIFIABLE HEALTH INFORMATION THAT ARE CREATED OR RETAINED BY OUR OFFICE. ANY REVISIONS OR AMENDMENTS TO THIS NOTICE WILL BE EFFECTIVE FOR ALL OF YOUR RECORDS OUR OFFICE HAS CREATED OR MAINTAINED IN THE PAST, AND FOR ANY OF YOUR RECORDS WE MAY CREATE OR MAINTAIN IN THE FUTURE. OUR ORGANIZATION WILL POST A COPY OF OUR CURRENT NOTICE IN OUR OFFICES IN A PROMINENT LOCATION, AND YOU MAY REQUEST A COPY OF OUR MOST CURRENT NOTICE DURING ANY OFFICE VISIT. B. IF YOU HAVE QUESTIONS REGARDING THIS NOTICE, PLEASE CONTACT: Brenda Aerts, Office Manager Watkins Surgical Supply 1391 E Sherman Blvd., Muskegon MI 49444 PH: 231-739-7158 FAX 231-739-8024 C. WE MAY USE AND DISCLOSE YOUR HEALTH INFORMATION IN THE FOLLOWING WAYS: The following categories describe the different ways which we may use and disclose your identifiable health information. 1. Treatment. Our organization may use your identifiable health information to provide services for you. For example, we may ask for the results of laboratory tests (such as blood or urine tests) to provide services that are relevant to your diagnosis. Some of the people who work for our organization may use or disclose your identifiable health information in order to provide services or assist others in providing services. Additionally, we may disclose your identifiable health information to others who may assist in your care, such as your physician, therapists, spouse, children or parents. 2. Payment. Our organization may use and disclose your identifiable health information in order to bill and collect payment for the services and items you may receive from us. For example, we may contact your health insurer to certify that you are eligible for benefits (and for what range of benefits) and we may provide your insurer with details regarding your treatment to determine if your insurer will cover or pay for your treatment or services. We also may use and disclose your identifiable health information to obtain payment from third parties that my be responsible for such costs, such as family members. Also, we may use your identifiable health information to bill you directly for services and items. 3. Health Care Operations. Our organization may use and disclose your identifiable health information to operate our business. As examples of the ways in which we may use and disclose your information for our operations, our organization may use your health information to evaluate the quality of care you received from us, or to conduct cost-management and business planning activities for our organization. 4. Appointment Reminders. Our organization may use and disclose your identifiable health information to contact you for delivery or services. 5. Health Related Benefits and Services. Our organization may use and disclose your identifiable health information to inform you of health-related benefits and services that may be of interest to you. 6. Release of Information to Family/Friends. Our organization may release your identifiable health information to a friend or family member that is helping you pay for your health care or who assists in taking care of you. 7. Disclosures Required by Law. Our organization will use and disclose your identifiable health information when we are required to do so by Federal, State or Local law. D. USE AND DISCLOSURE OF YOUR IDENTIFIABLE HEALTH INFORMATION IN CERTAIN SPECIAL CIRCUMSTANCES. 1. Public Health Risks. Our organization may disclose your identifiable health information to public health authorities that are authorized by law to collect information for the purpose of: *maintaining vital records, such as births and deaths; *reporting child abuse and neglect; *preventing or controlling disease, injury or disability; *notifying a person regarding potential exposure to a communicable disease or condition; *reporting reactions to drugs or problems with products or devises; notifying individuals if a product or devise they may be using has been recalled; *notifying appropriate government agencies and authorities regarding potential abuse or neglect of an adult parent (including domestic violence), however, we will only disclose this information if the patient agrees or we are required or authorized by law to disclose this information; and *notify your employer under limited circumstances related primarily to workplace injury or illness or medical surveillance. 2. Health Oversight Activities. Our organization may disclose your identifiable information to a health oversight agency for activities authorized by law. Oversight activities can include investigations, inspections, audits, surveys, licensure and disciplinary actions; civil, administrative and criminal procedures or actions; or other activities necessary for the government to monitor government programs, compliance with civil right laws and the health care system in general. 3. Lawsuits and Similar Proceedings. Our organization may use and disclose your identifiable health information in response to a court or administrative order, if you are involved in a lawsuit or similar proceeding. We also may disclose your identifiable health information in response to a discovery request, subpoena or other lawful process by another party involved in the dispute, but only if we have made an effort to inform you of the request or to obtain an order protecting the information the party has requested. 4. Law Enforcement. We may release identifiable health information if asked to do so by a law enforcement official; *regarding a crime victim in certain situations, if we are unable to obtain the persons agreement; *concerning a death we believe might have resulted from criminal conduct; *regarding criminal conduct at our offices; *in response to a warrant, summons, court order, subpoena or similar legal process; *to identify/locate a suspect, material witness, fugitive or missing person; and *in an emergency, to report a crime (including the location or victim of the crime or the description, identity or location of the perpetrator). 5. Serious Threats to Health or Safety. Our organization may use and disclose your identifiable health information when necessary to reduce or prevent a serious threat to your health and safety or the health and safety of another individual or the public. Under these circumstances, we will only make disclosures to a person or organization able to help prevent the threat. 6. Military. Our organization may disclose your identifiable health information if you are a member of the U.S. or foreign military forces (including veterans) and it is required by the appropriate military command authorities. 7. National Security. Our organization may disclose your identifiable health information to federal officials for intelligence and national security activities authorized by law. We also may disclose your identifiable health information to federal officials in order to protect the President, other officials or foreign heads of state, or to conduct investigations. 8. Inmates. Our organization may disclose your identifiable health information to correctional institutions or law enforcement officials if you are an inmate or under the custody of a law enforcement official. Disclosure for these purposes would be necessary: *for the institution to provide health care services to you; *for the safety and security of the institution and/or *to protect your health and safety or the health and safety of other individuals. 9. Worker?s Compensation. Our organization may release your identifiable health information for worker?s compensation and similar programs. E. YOUR RIGHTS REGARDING YOUR IDENTIFIABLE HEALTH INFORMATION You have the following rights regarding the identifiable health information that we maintain about you: 1. Confidential Communications. You have the right to request that our organization communicate with you about your health and related issues in a particular manner or at a certain location. For instance, you may ask that we contact you at home, rather than work. In order to request a type of confidential communication, you must make a written request to Brenda Aerts, Office Manager, Watkins Surgical Supply, 1391 E. Sherman Blvd, Muskegon, MI 49444 (231) 739-7158 specifying the requested method of contact or the location where you wish to be contacted. Our organization will accommodate reasonable requests. You do not need to give a reason for your request. 2. Requesting Restrictions. You have the right to request a restriction in our use or disclosure of your identifiable health information for treatment, payment or health care operations. Additionally, you have the right to request that we limit our disclosure of your identifiable health information to individuals involved in your care or the payment for your care, such as family members and friends. We are not required to agree to your request. However, if we do agree, we are bound by our agreement except when otherwise required by law, in emergencies or when the information is necessary to provide services to you. In order to request a restriction in our use of disclosure of your identifiable health information, you must make your request in writing to Brenda Aerts, Office Manager, Watkins Surgical Supply, 1391 E. Sherman Blvd., Muskegon, MI 49444 (231) 739-7158. Your request must describe in a clear and concise fashion: *the information you wish restricted *whether you are requesting to limit our organizations use, disclosure or both; *to whom you want the limits to apply. 3. Inspection and Copies. You have the right to inspect and obtain a copy of the identifiable health information that may be used to make decisions about you, including patient medical records and billing records, but not insluding psychotherapy notes. You must submit your request in writing to Brenda Aerts, Office Manager, Watkins Surgical Supply, 1391 E. Sherman Blvd., Muskegon MI 49444 (231) 739-7158 in order to inspect and/or obtain a copy of your identifiable health information. Our organization may charge a fee for the costs of copying, mailing, labor and supplies associated with your request. Our organization may deny your request to inspect and/or copy in certain limited circumstances, however, you may request a review of our denial. Reviews will be conducted by another member of our staff chosen by us. 4. Amendment. You may ask us to amend your health information if you believe it is incorrect or incomplete and you may request an amendment for as long as the information is kept by or for our organization. To request an amendment, your request must be submitted in writing to Brenda Aerts, Office Manager, Watkins Surgical Supply, 1391 E. Sherman Blvd., Muskegon MI 49444 (231) 739-7158. You must provide us with a reason that supports your request for amendment. Our organization will deny your request if you fail to submit your request and the reason supporting your request in writing. Also, we may deny your request if you ask us to amend information that is: *accurate and complete; *not part of the identifiable health information kept by or for our organization; *not part of the identifiable health information which you would be permitted to inspect and copy; or *not created by our organization, unless the individual or entity that created the information is not available to amend the information. 5. Accounting of Disclosures. All of our patients have the right to request an ?accounting of disclosures?. An ?accounting of disclosures? is a list of certain disclosures our organization has made of your identifiable health information.. In order to obtain an ?accounting of disclosures?, you must submit your request in writing to Brenda Aerts, Office Manager, Watkins Surgical Supply, 1391 E Sherman Blvd., Muskegon, MI 49444 (231)739-7158. All requests for an ?accounting of disclosures? must state a time period which may not be longer that six (6) years and may not include dates before April 14, 2003. The first list you request within a 12-month period is free of charge, but our organization may charge you for additional lists within the same 12-month period. Our organization will notify you of the costs involved with additional requests and you may withdraw your request before you incur any costs. 6. Right To A Paper Copy Of This Notice. You are entitled to receive a paper copy of our notice of privacy practices. You may ask us to give you a copy of this notice at any time. To obtain a paper copy of this notice, contact any staff member at Watkins Surgical Supply, 1391 E. Sherman Blvd., Muskegon MI 49444 (231)739-7158. 7. Right To File A Complaint. If you believe that your privacy rights have been violated, you may file a complaint with our organization or with the Secretary of The Department of Health and Human Services. To file a complaint with our organization, contact Brenda Aerts, Office Manager, Watkins Surgical Supply., 1391 E. Sherman Blvd., Muskegon MI 49444 (231)739-7158. All complaints must be submitted in writing. You will not be penalized for filing a complaint. 8. Right To Provide An Authorization For Other Uses And Disclosures. Our organization will obtain your written authorization for uses and disclosures that are not identified by this notice or permitted by applicable law. Any authorization you provide to us regarding the use and disclosure of your identifiable health information may be revoked at any time in writing. After you revoke your authorization, we will no longer use or disclose your identifiable health information for the reasons described in the authorization. Please note, we are required to retain records for your care and services. Watkins Pharmacy & Surgical Supply PATIENTS RIGHTS AND RESPONSIBILITIES RIGHTS You, as a patient of Watkins Pharmacy & Surgical Supply, have the right... *To be treated with dignity, courtesy and respect regardless of race, religion, politics, gender, social status, age or handicap. *To be provided service in a timely manner and receive a timely response when assistance is needed *To make informed decisions regarding services *To be involved in resolving conflicts about service *To have complaints heard, reviewed and if possible, resolved *To confidentiality *To privacy and security *To have property respected RESPONSIBILITIES You, as a patient of Watkins Pharmacy & Surgical Supply are responsible for.... *Notifying Watkins when you will not be available for scheduled services/visits *Notify Watkins of a change of address *Notifying Watkins of any change in physician or insurance coverage *Notify Watkins of needed equipment repair *Notifying Watkins when equipment is no longer needed so that pick-up may be arranged *Notifying Watkins of any undue incident involving staff or equipment *Proper care/maintenance of rental equipment and returning equipment in good working condition *Payment for any service/equipment not covered by your insurance Watkins Pharmacy & Surgical Supply Co. CREDIT/COLLECTION DEPARTMENT 1391 E. Sherman Blvd., Muskegon MI 49444 231-739-7158 or 1-800-777-2717...FAX 231-739-8024 FINANCIAL POLICY Watkins Surgical Supply has established the following revised payment policy effective March 1, 2003. Fees must be paid by one of the following terms. 1. Watkins Surgical Supply will submit claims to insurance plans according to the terms of the individual agreements with the insurance company when they exist. The patients co-insurance is due at the time of service and is payable by cash, check, MasterCard, Visa, Discover or American Express. A service charge of 1.5% will be added to any account with a balance over 30 days past due to cover the costs incurred to send additional statements. 2. In the instance where the insurance plan of the patient is not under contract with Watkins Surgical Supply, our policy is to submit the claim to the insurance company as a courtesy to the patient. Prompt pay law in Michigan states the insurance company is to pay within 45 days of receipt of the claim. It is the patients responsibility to follow up with their insurance company. The Privacy Act prohibits Watkins Surgical Supply from obtaining information on the processing of an unassigned claim. 3. Balances that are ?patient responsibility? to include non-covered services, 60-day aged accounts, deductibles, denied services and self-pay are payable by one of two methods: (Self-Pay is defined as patient without insurance, motor vehicle accidents and ?other liability? accidents) A) Paid in full B) 3 equal monthly payments until paid in full 4. Routine waiver of Medicare coinsurance and deductible is considered fraud under Medicare guidelines and therefore against the law. It is possible on a case-by-case basis for Watkins Surgical Supply to declare an account as a ?charity/hardship? account and assist patients with financial difficulties. If patients are unable to pay we encourage contacting our Credit/Collections department at 231-739-7158 or 800-777-2717 to discuss arrangements. 5. Secondary insurance claims will be submitted as a courtesy to the patient. However, the patient will remain responsible for the balance except in the instances where Watkins Surgical Supply is in contractual arrangement with the secondary insurance. The above ?patient responsibility? rule will apple. 6. Watkins Surgical Supply makes every attempt to collect delinquent accounts in-house. Failure to abide by our payment policies will put the patient at risk of being placed with a collection agency. Once an account is placed with an agency, the patient must deal directly with that collection agency. Therefore, prompt payment is encouraged. WATKINS PHARMACY AND SURGICAL SUPPLY 1391 E. Sherman Blvd. Muskegon MI 49444 231-739-7158 800-777-2717 FX: 231-739-8024 *Notice Of Privacy Practices* *Patients Rights & Responsibilities* *Financial Policy*
Welcome to Watkins Pharmacy & Surgical Supply. As your local Good Neighbor Pharmacy, we offer quality products at affordable prices, while providing the personalized attention and customer service you expect from a local business. As your neighbors, we live, work and play in the same community as you and your family. We’re the local business owners you see in the neighborhood, at the school play, and volunteering at the local charity. We believe it is our responsibility to take care of our community and our neighbors, and it’s one we take very seriously. We thrive on the opportunity to serve you and your family to the best of our abilities because your business and your health are very important to us. Get to know your neighbor – we’re here to help.