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Privacy Statement 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. WHO WE ARE This Notice describes the privacy practices of QoL Meds, its pharmacists, and other personnel who provide services at or for the pharmacy. OUR PRIVACY OBLIGATIONS We are required by law to maintain the privacy of health information about you (Protected Health Information) and to provide you with this Notice of our legal duties and privacy practices with respect to your Protected Health Information. When we use or disclose your Protected Health Information, we are required to abide by the terms of this Notice (or other notice in effect at the time of the use or disclosure). USES AND DISCLOSURES REQUIRING YOUR WRITTEN AUTHORIZATION For any purpose other than the ones described below, we only may use or disclose your Protected Health Information when you grant us your written authorization on our authorization form. For example, we must obtain your written authorization prior to using your Protected Health Information for marketing purposes. PERMISSIBLE USES AND DISCLOSURES WITHOUT YOUR WRITTEN AUTHORIZATION We may use and disclose your Protected Health Information without your written authorization for the following purposes:
YOUR INDIVIDUAL RIGHTS 1. For further information; Complaints. If you desire further information about your privacy rights, are concerned that we have violated your privacy rights or disagree with a decision that we made about access to your Protected Health Information, you may contact our Privacy Officer. You may also file written complaints with the Director, Office of Civil Rights of the U.S. Department of Health and Human Services. Upon request, the Privacy Officer will provide you with the correct address for the Director, or you may obtain this information from the Office of Civil Rights website www.hhs.gov/ocr/regmail.html. We will not retaliate against you if you file a complaint with us or the Director. 2. Right to Request Additional Restrictions. You may request restrictions on our use and disclosure of your Protected Health Information (1) for treatment, payment and health care operations, (2) to individuals (such as family member, other relative, close personal friend or any other person identified by you) involved with your care or with payment related to your care, or (3) to notify or assist in the notification of such individuals regarding your location and general condition. While we will consider all request additional restrictions, please obtain a request form from our Privacy Office and submit the completed form to the Privacy Office. We will send you a written response. 3. Right to Receive Communications by Alternative Means or at Alternative Locations. You may request, and we will accommodate, any reasonable written request for you to receive your Protected Health Information by alternative means of communication or at alternative locations. 4. Right to Inspect and Copy Your Health Information. You may request access to your health record file and billing records maintained by us in order to inspect and request copies of the records. If you desire access to your records, please obtain a record request form from the Privacy Office and submit the completed form to the Privacy Office. If you request copies, we will charge you no more than the actual cost of copying (including reasonable staff time) and postage, if you request that we mail the copies to you. 5. Revocation of Your Authorization. You may revoke your authorization, except to the extent that we have taken action in reliance upon it, by delivering a written revocation statement to the Privacy Office identified below. A form of Written Revocation is available from the Privacy Office. 6. Right to Amend Your Records. You have the right to request that we amend your Protected Health Information maintained in your health record file or billing records. If you desire to amend your records, please obtain an amendment request form from the Privacy Office and submit the completed form to the Privacy Office. We will comply with your request unless we believe that the information that would be amended is accurate and complete or other special circumstances apply. 7. Right to Receive an Accounting of Disclosures. Upon request, you may obtain an accounting of certain disclosures of your Protected Health Information made by us during any period of time prior to the date of your request provided such period does not exceed six years and does not apply to disclosures that occurred prior to April 14, 2003. If you request an accounting more than once during a twelve (12) month period, we will charge you a reasonable, cost-based fee for the accounting statement. 8. Right to Receive Paper Copy of this Notice. Upon request, you may obtain a paper copy of this Notice, even if you agreed to receive such notice electronically. EFFECTIVE DATE AND DURATION OF THIS NOTICE 1. Effective Date. This Notice is effective on April 14, 2003. 2. Right to Change Terms of this Notice. We may change the terms of this Notice at any time. If we change this Notice, we may make the new notice terms effective for all your Protected Health Information that we maintain, including any information created or received prior to issuing the new notice. If we change this Notice, we will post the new Notice on our Internet Site at www.qolmeds.com. You also may obtain any new notice by contacting the Privacy Office. PRIVACY OFFICE You may contact the Privacy Office at: QoL Meds 4900 Perry Highway Building 2 Pittsburgh, Pennsylvania 15229 Telephone: (800)663-4829 Facsimile: (877)635-2344 Email: pharmacy@qolmeds.com |
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