Sav-Mor Franchising, Inc.
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.
At Sav-Mor Franchising, Inc., we're committed to providing quality customer service and keeping you informed. At this time, we want to tell you about a federal requirement for privacy and security. The U.S. Department of Health and Human Services set standards for ensuring the privacy and security of personal health information (PHI). These regulations went into effect on April 14, 2003 and April 21, 2005. We are committed to keeping your health care information confidential.
You have the following rights with respect to Protected Health Information (PHI) about you:
- You may obtain a paper copy of this notice upon request at any time . To obtain a paper copy, contact the store Privacy Officer at: (248) 348-1570
- You may request a restriction on certain uses and disclosures of PHI. You have the right to request a restriction on uses or disclosure of your PHI. This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment, or healthcare operations, unless where required by law, State, or Federal program. However, if this restriction impedes the payment process, you are responsible for paying for the service in full at the time services are rendered. If your out-of-pocket payment for a health care item is not honored (i.e. check bounces), then we are not obligated to abide by the requested restriction. Send a written request request including: (a) The information to be restricted, (b) what kind of restriction you are requesting, and (c) to whom the limits apply to the store Privacy Officer at: 43155 West Nine Mile Road, Novi MI, 48376. We are not, however, required to agree to those restrictions. If the pharmacist believes it is in your best interest to permit use and disclosure of your PHI, your PHI will not be restricted.
- You may inspect and obtain a copy of your PHI. You have the right to access and have copies made of the PHI about you contained in a designated record set for as long as we maintain the PHI. The designated record set will usually include prescription and billing records. To inspect or request copies of PHI about you, you must send a written request to the store Privacy Officer at: 43155 West Nine Mile Road, Novi MI, 48376. We may charge you a fee for the costs of copying, mailing, labor and supplies that are necessary to fulfill 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. You may also request an electronic, “machine-readable” copy of your PHI. If you decline to accept any of the electronic formats that are readily producible, you will be provided with a hard copy.
- You may request an amendment of your PHI. If you feel the PHI we maintain about you is incomplete or incorrect, you may request that we amend it. You may request this as long as we maintain the PHI. To request an amendment, send a written request to the store Privacy Officer at: 43155 West Nine Mile Road, Novi MI, 48376. 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 a rebuttal to your statement.
- You may receive an accounting of disclosures of your PHI. You have the right to request an accounting of most disclosures made after April 14, 2003 (other than those relating to treatment, payment, or health care operation). The accounting will exclude certain disclosures, such as disclosures made directly to you, disclosures you authorize, disclosures to family members or friends involved in your care, and disclosures for notification purposes. The right to receive an accounting of disclosures is subject to certain other exceptions, restrictions, and limitations. To request an accounting, submit a written request to the store Privacy Officer at: 43155 West Nine Mile Road, Novi MI, 48376. 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.
- You may request PHI communication by alternative mean or alternative locations. For instance, you may request that we contact you about medical matters in writing or at a different address or post office box. To request alternative communication of PHI about you, send a written request to the store Privacy Officer at: 43155 West Nine Mile Road, Novi MI, 48376. Your request must state how or where you would like to be contacted. We will attempt to accommodate all reasonable requests.
Protected Health Information (PHI) may be used and disclosed by us in the following manners:
- Your PHI will be used for treatment. 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.
- Your PHI will be used for payment purposes. If you have insurance coverage, we will contact your insurer or pharmacy benefit manager to determine whether it will pay for your prescription and the amount of your copayment. We will bill you or a third-party payor for the cost of the 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.
- Your PHI will be used for health care operations. 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.
- Your PHI may likely be disclosed to our business associates. There are some services provided by us through contracts with business associates. Examples include: pharmacy Franchise Corporation, pharmacy computer software vendor, prescription insurance companies or pharmacy benefit managers, claim processing vendors, our legal counsel in cases of litigation. To protect PHI about you, we require the business associate to appropriately safeguard the PHI.
- Your PHI may likely be disclosed to 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 personвЂ™s involvement in your care or payment related to your care.
- Your PHI may likely be disclosed to provide health-related 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.
- Your PHI may likely be disclosed to the Food and Drug Administration (FDA). We may disclose to the FDA, or persons under the jurisdiction of the FDA, 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.
- Your PHI may likely be disclosed in Worker's Compensation cases. We may disclose PHI about you as authorized by and as necessary to comply with laws relating to workerвЂ™s compensation or similar programs established by law.
- Your PHI may likely be disclosed to Public Health authorities. 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.
- Your PHI will be disclosed as required by law. We must disclose PHI about you when required to do so by law.
- Your PHI may likely be disclosed for law enforcement purposes. We may disclose PHI about you for law enforcement purposes as required by law or in response to a valid subpoena or other legal process.
- We are permitted to disclose your PHI for research purposes. We may disclose PHI about you to researchers when an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your information has approved their research.
- We are permitted to disclose your PHI to 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.
- We are permitted to disclose your PHI to 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.
- We are permitted to disclose your PHI for purposes of 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 your general condition.
- We are permitted to disclose your PHI to correctional institutions. If you are or become an inmate of a correctional institution, we may disclose PHI to the institution or its agents when necessary for your health or the health and safety of others.
- We are permitted to disclose your PHI to avert a serious threat to health or safety. We may use or 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.
- We are permitted to disclose your PHI to the military. 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.
- We are permitted to disclose your PHI for 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.
- We are permitted to disclose your PHI to 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.
- We are permitted to disclose your PHI in cases 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.
Sav-Mor Franchising, Inc. 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 authorization in writing at any time. Send written request the store Privacy Officer at:
43155 West Nine Mile Road, Novi MI, 48376. Upon receipt of the written request for revocation, we will stop using or disclosing information about you, except to the extent that we have already taken action in reliance on the authorization. If revoked, we may not be able to service your pharmacy health care needs.
Electronic data collection
- We may collect personally identifiable information (name, e-mail address, physical address, and other unique identifiers) only if specifically and knowingly provided by you.
- Personally identifying information collected will be used only for such purposes as described at the point of collection.
- We will protect personal information that you share with us. This store does not disclose, give, sell, or transfer any personal information to third parties.
For more information about the Pharmacy's privacy practices or to report a problem, you may contact Sav-Mor Franchising, Inc. at: (248) 348-1570. If you believe your rights have been violated, you can file a complaint with the store Privacy Officer or with the Secretary of Health and Human Services. There will be no retaliation for filing a complaint.
Sav-Mor Franchising, Inc. Rev. 2013
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