Boothwyn Pharmacy, Inc. 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. Boothwyn Pharmacy, Inc. 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 indentify you and that relates to your past, present, or future physical or mental health condition and related health care services. 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 specific purposes that are permitted or required by law. The Notice also describes your rights with respect to PHI about you. Boothwyn Pharmacy, Inc. 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 PHI we maintain. Upon request, we will provide a 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 copy, contact the Privacy Officer at 610-485-1130 ? 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 the Privacy Officer. 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 Boothwyn Pharmacy, Inc. 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 the Privacy Officer. We may charge you a fee for the costs of copying, mailing, or other supplies that are necessary to grant your request (see States Rights Sections). We may deny your request to inspect and copy in certain limited circumstances. If you are denied access 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 the Privacy Officer. 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 give you a rebuttal to your statement. ? Receive an accounting of disclosures of PHI. You have the right to receive an accounting of 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 and 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 the Privacy Officer. Your request must specify the time period, but may not be longer than six years. You may be charged for the cost of providing an accounting. 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 the Privacy Officer. Your request must state how or when you would like to be contacted. We will accommodate all reasonable requests. ? Revoke your consent to use or disclose PHI. You may revoke consent 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 consent. We may refuse to continue to treat a customer that revokes his or her consent. State Rights- Pennsylvania You have the following additional rights with respect to PHI under Pennsylvania State law: ? You or your designee including your attorney, has the right to access and copy your medical charts and records maintained by us, without the use of a subpoena duces tecum, for your own use. [42 Pa. Cons. Stat. Ann. 6155.1]. As of 2002, copying fees may not exceed $16.24 for searching for and retrieving the records, $1.09 per page for paper copies for the first 20 pages, 82 cents per page for pages 21 through 60 and 28 cents per page for pages 61 and thereafter; $1.62 per page for copies from microfilm; plus the actual cost of postage, shipping or delivery. [42 Pa Cons. Stat. Ann. 6152 and 6155; 31 Pa. Bulletin Doc. No 01-2142 (where, in accordance with statutory authority, Secretary of Health adjusted copying costs to reflect changes in the customer price index).] No other changes for the retrieval, copying and shipping or delivery are permitted without prior approval of the requestor. ? With respect to cancer, we are required to reports cases of cancer to the Department of Health. [Pa. Stat. Ann. Tit. 35 5636]. These reports are confidential and are not open to public inspection or dissemination. [Id.] The information may be collected and analyzed by the Department and its contractors, as well as researchers, who are subject to strict supervision to ensure that the use of the reports is limited to specific research purposes. ? With respect to HIV/AIDS, Pennsylvania?s Confidentiality of HIV-related information in the course of providing any health or social services or pursuant to the patient?s authorization may disclose or be compelled to disclose that information without the patient?s written consent. [Pa. Stat. Ann. Tit. 35, 7607.] ? With respect to substance Abuse, The Pennsylvania Drug and Alcohol Abuse Control Act requires that all patient records of drug and alcohol abuse, and the information contained therein, are confidential and may not be disclosed without the patient?s consent. [Pa. Stat. Ann. Tit. 71, 1690.108.] Even with the patient?s consent, this information may only be released to medical personnel for purposes of diagnosis and treatment of the patient or to government or other officials exclusively for the purpose of obtaining benefits due to the patient as a result of his alcohol or drug dependency. 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 without your written consent. ? We will use PHI for treatment. 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 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: Boothwyn Pharmacy, Inc. 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 without your written authorization for the following purposes: ? Business associates: There are some services provided by us through contracts with business associates. Examples include the analysis or prescription costs and their trends for groups and sub-groups of patient populations. 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 enter into written contracts and require satisfactory assurance from 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 to your care. ? 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. ? 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 replacements. ? Worker?s compensation: We may disclose PHI about you to the extent authorized by and to the extent necessary to comply with laws relating workers? compensation or other 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. ? 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 health care system, government programs and compliance with civil rights laws. ? Judicial and Administrative proceedings: If you are involved in a lawsuit or 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 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. ? 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 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 and or the health and safety of others. ? 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 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, of 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 Requiring Your Written Authorization Boothwyn Pharmacy Inc. will obtain you 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. For More Information or to Report a Problem If you have questions or would like additional information about Boothwyn Pharmacy Inc.?s privacy practices, you may contact Athena Czernac. If you believe your privacy rights have been violated, you can file a complaint with the Athena Czernac or with the Secretary of Health and Human Services. There will be no retaliation for filing a complaint. Effective Date This Notice is effective as of April 15, 2003. The terms of this notice apply to all records containing your identifiable health information that are created or retained by our practice. We reserve the right to revise or amend our notice of privacy records. Any revision or amendment to this notice will be effective for all of your records our practice has created or maintained in the past, or 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. Consent Form This consent form is for Boothwyn Pharmacy Inc. The purpose of the consent form is to inform you, the patient, how your personal health information is used and/or disclosed by this provider or organization. We want you to be fully aware or what we do with your information so you can provide us with your consent in order to us to treat your health care needs, receive payment for services rendered, and allow administrative and other types of health care operations to happen, which are part of normal business activities of the provider or organization. Your consent I understand that as part of my health care, this organization originates and maintains health records describing by health history, symptoms, test results, diagnoses, treatment, and plans for future care or treatment. I understand that this information serves as: ? A basis for planning my care and treatment ? A means of communication among the many health professionals who contribute to my care. ? A source of information for applying my diagnosis/es and other health information to my bill(s). ? A means by which my health plan or health insurance company can verify that services billed were actually provided. ? A tool for routine health care operations in this organization, such as ensuring that we have quality processes and programs in place and making sure that the professionals who provide your care and competent to do so. I understand that: ? I have been provided with a Notice of Information Practices that provides specific examples and descriptions of how my personal health information is used and disclosed by Boothwyn Pharmacy Inc; ? I have the right to review this Notice of Information Practices prior to signing this consent; ? Boothwyn Pharmacy Inc can change its Notice of Information Practices but notify me of those changes before they are put into practice and will mail me a copy of the new Notice to the address that I have provided; ? I have the right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment or health care operations and that Boothwyn Pharmacy Inc. is not required to agree to those restrictions; ? Any restrictions to which Boothwyn Pharmacy Inc. agrees to will be respected. ? I may revoke this consent in writing at any time. Further, I am aware that Boothwyn Pharmacy Inc. can proceed with uses and disclosures that pertain to treatment, payment, or healthcare issues that took place before the consent was revoked. To request a restriction on the use and disclose of your personal health information related to your treatment, payment for service, or for the health care operations of Boothwyn Pharmacy Inc., please do so after reading the Notice of Information Practices. You may use this consent form to request a restriction.
Welcome to Boothwyn Pharmacy. 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.