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NOTICE OF PRIVACY PRACTICES
This notice describes how medical information about patients may be used and
disclosed and how patients can get access to this information.
Please read it carefully. These procedures are in complete compliance with the Health
Insurance Portability and Accountability Act ("HIPAA").
Bellegrove will ask you to sign an Acknowledgment that you have received this Notice of
Privacy Practices ("Notice"). This Notice describes, in accordance with the HIPAA
Privacy Regulation, how Bellegrove may use and disclose your protected health
information 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 and Bellegrove's duties with respect to protected health information about you.
Bellegrove will store information provided by you in the computer system. That
information will include your name, address, phone number and other identifying
information. In addition, any information that you provide concerning drugs that you are
taking, medical conditions you may have, allergies, and other matters affecting your
health will be stored in the computer.
TREATMENT, PAYMENT, AND HEALTH CARE OPERATIONS
We will use your health care information to treat you. For example, we will use health
care information to dispense prescription medications. We may also disclose your
information to other health care providers for the purpose of treatment.
We will use your health care information to receive payment for products and services.
For example, we may contact your third party payor (for example, insurer or
pharmaceutical benefits manager) to determine whether your program will pay for your
prescription. We will bill you and/or a third party payor for the cost of prescription
medications dispensed to you. The information on or accompanying the bill may include
your identification, as well as the prescriptions you are taking.
We will use your health care information to carry out health care operations. For
example, we may use information in your health record to monitor the quality of
pharmacist performance and to train pharmacy personnel.
USES AND DISCLOSURES THAT ARE EITHER PERMITTED OR REQUIRED BY THE REGULATION
We will use your health care information to treat you. For example, we will use health
care information to dispense prescription medications. We may also disclose your
information to other health care providers for the purpose of treatment.
We will use your health care information to receive payment for products and services.
For example, we may contact your third party payor (for example, insurer or
pharmaceutical benefits manager) to determine whether your program will pay for your
prescription. We will bill you and/or a third party payor for the cost of prescription
medications dispensed to you. The information on or accompanying the bill may include
your identification, as well as the prescriptions you are taking.
We will use your health care information to carry out health care operations. For
example, we may use information in your health record to monitor the quality of
pharmacist performance and to train pharmacy personnel.
OTHER REQUIRED OR PERMITTED DISCLOSURES
We may disclose your health care information to the following entities and/or under
given circumstances:
•to the Food and Drug Administration (FDA) relative to adverse events regarding drugs,
foods, supplements, and other health products or to post marketing surveillance to
enable product recalls, repairs, or replacement;
•to public health or legal authorities charged with preventing or controlling disease,
injury, or disability;
•to law enforcement agencies as required by law or in response to a valid subpoena or
other legal process;
•to health oversight agencies (medical licensing boards, e.g.) for activities authorized by
law such as audits, investigations, and inspections necessary for Bellegrove's licensure
and for the government to monitor the health care system, etc.;
•in response to a court order, administrative order, subpoena, discovery request, or
other lawful process by another person involved in a dispute involving a patient, but only
if efforts have been made to tell the patient about the request or to obtain an order
protecting the requested health care information;
•as authorized by and as necessary to comply with laws relating to worker's
compensation or similar programs established by law;
•whenever required to do so by law;
•to a coroner or medical examiner when necessay, for example, to identify a deceased
person or to determine a cause of death, or to funeral directors consistent with
applicable law to carry out their duties;
•to organ procurement organizations or other entities engaged in the procurement,
banking, or transplantation of organs for the purpose of tissue donation and transplant,
consistent with applicable law;
•to notify, or assist in notifying, a family member, personal representative, or another
person responsible for the patient's care, of the patient's location, or general condition;
•to a correctional institution or its agents, if a patient is or becomes an inmate of such an
institution, when necessary for the patient's health or the health and safety of others;
•when necessary to prevent a serious threat to the patient's health and safety or the
health and safety of the public or another person;
•as required by military command authorities, when the patient is a member of the
armed forces, and to appropriate military authority about foreign military personnel;
•to authorized federal officials for intelligence, counterintelligence, and other national
security activities authorized by law;
•to authorized federal officials so they may provide protection to the president, other
authorized persons, or foreign heads of state or conduct special investigations;
•to a government authority, such as a social service or protective services agency, if
Bellegrove reasonably believes the patient to be a victim of abuse, neglect, or domestic
violence, but only to the extent required by law, if the patient agrees to the disclosure, or
if the disclosure is allowed by law and Bellegrove believes it is necessary to prevent
serious harm to the patient or to 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
the patient.
MORE STRINGENT LAWS
If your state has a law or regulation that is more stringent than the HIPAA Regulation,
please refer to the accompanying insert entitled State Laws More Stringent Than HIPAA
where that more stringent law will be reflected.
AUTHORIZED USE AND DISCLOSURE
We will obtain your written Authorization before using or disclosing protected health
information about you for purposes other than those listed above or otherwise permitted
or required by law. You may revoke an Authorization in writing at any time. Such
revocations must be made in writing. Upon receipt of the written revocation, we will stop
using or disclosing protected health information about you, except to the extent that we
have already taken action in reliance on the Authorization.
THE PATIENT'S RIGHTS
RESTRICTION REQUESTS
You have the right to request that we restrict how your protected health information is
used or disclosed in carrying out treatment, payment, or health care operations. Such
requests must be made in writing to the Privacy Office, Bellegrove, P.O. Box 1828,
Bellevue, WA 98004. We are not required to agree to the requested restrictions. If,
however, we do agree to the requested restrictions, that agreement will be binding on us.
ALTERNATIVE MEANS OF COMMUNICATION
You have the right to request that our communications to you concerning your health
care information be made by alternative means or at alternative locations. For example,
you may wish us to communicate in some way other than mailing to your home address
or calling your home telephone number. Such requests must be made in writing to the
Privacy Office, Bellegrove, P.O. Box 1828, Bellevue, WA 98004. We will comply with a
reasonable request for such an alternative.
ACCESS
You have the right to inspect and obtain a copy of your protected health information. You
have the right to access and copy protected information about you contained in the
designated record set for as long as we maintain your protected health information. The
designated record set usually will include prescription and billing records. To receive a
copy of your protected health information, you must send a written request to the
Privacy Office, Bellegrove, P.O. Box 1828, Bellevue, WA 98004. We may charge you a
fee for the costs of copying, mailing, or other supplies that are necessary to grant your
request. We may also deny your request to inspect and copy in limited circumstances.
If you are denied access to your protected health information in most cases you may
request that the denial be reviewed.
HEALTH CARE INFORMATION AMENDMENTS
If you feel that the protected health information 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 protected health information. A request for an Amendment must
be made in writing. Forms for making such requests, which are available in our
pharmacies, should be completed and sent to the Privacy Office, Bellegrove, P.O. Box
1828, Bellevue, WA 98004. You must include a reason that supports your request. In
certain cases, we may deny the request. If the request for Amendment is denied, you
have the right to file a statement of disagreement with the decision, and we may give a
rebuttal to your statement.
ACCOUNTING
For most purposes other than treatment, payment, or health care operations, you have
the right to receive an Accounting of the disclosures we made, on or after April 14, 2003,
of your protected health information. The Accounting will exclude disclosures we may
have made directly to you, disclosures to friends or family members involved in your
care, and disclosures for purposes you specifically authorized in writing. The right to
receive an Accounting is subject to certain other exceptions, restrictions, and limitations.
A request for an Accounting must be made in writing. The time period for the requested
accounting must be specified and it 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 within that period. We
will notify you of the cost involved and you may choose to withdraw or modify the
request at that time.
NOTICE OF PRIVACY PRACTICES
You have a right to receive a paper copy of this Notice from us upon request even if you
have already received the Notice electronically (for example, on the Internet).
BELLEGROVE'S DUTIES
Bellegrove takes its responsibility for maintaining your protected health information in
confidence very seriously. Protected health information means information about you
that may identify you and that relates to your past, present or future physical or mental
health or condition and related health care services. It also includes basic demographic
information. We are required by law to maintain the privacy of protected health
information and to provide you with a Notice of Privacy Practices including our legal
duties with respect to protected health information.
EFFECTIVE DATE
This Notice of Privacy Practices is effective as of April 14, 2003.
The Health Insurance Portability and Accountability Act ("HIPAA") Notice of Privacy Practices
WASHINGTON - Unless authorized by you, we will not disclose your health care
information, except if the recipient needs to know the information and the disclosure is:
(a) to a person who the pharmacist reasonably believes is providing health care to you;
(b) to any other person who requires health care information for healthcare education, or
to provide planning, quality assurance, peer review, or administrative, legal, financial, or
actuarial services to the pharmacy; or for assisting the pharmacy in the delivery of
health care and the pharmacist reasonably believes that the person will not use or
disclose the health care information for any other purpose and will take appropriate
steps to protect the health care information; (c) to any other health care provider
reasonably believed to have previously provided health care to you, to the extent
necessary to provide health care to you, unless you have instructed the pharmacy in
writing not to make the disclosure; (d) to any person if the pharmacist reasonably
believes that disclosure will avoid or minimize an imminent danger to your or another
individual's health or safety, however there is no obligation on the part of the pharmacist
to so disclose; (e) oral, and made to your immediate family members, or any other
individual with whom you have a close personal relationship, if made in accordance with
good medical or other professional practice, unless you have instructed us in writing not
to make the disclosure; (f) to a health care provider who is the successor in interest to
the pharmacy; (g) to a person who obtains information for purposes of an audit, if that
person agrees in writing to remove or destroy, at the earliest opportunity consistent with
the purpose of the audit, information that would enable you to be identified and not to
disclose the information further, except to accomplish the audit or report unlawful or
improper conduct involving fraud in payment for health care by a health care provider or
patient, or other unlawful conduct by the pharmacy; (h) to an official of a penal or other
custodial institution in which you are detained; or (i) to provide directory information,
unless you have instructed the pharmacy not to make the disclosure.
We will not disclose any information regarding an individual's treatment for a sexually
transmitted diseases, except in situations where the subject of the information has
provided us with a written authorization allowing the release or where we are authorized
or required by state or federal law to make the disclosure.
If you are a minor who has lawfully provided consent for treatment and you wish
Bellegrove to treat you as an adult for purposes of access to and disclosure of records
related to such treatment, please notify a pharmacist.
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