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THREE
LAKES PHARMACY
THREE LAKES, WI
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
Under applicable law, we are required to protect the privacy of
your individual health information (information we refer to in this
notice as "Protected Health Information"). We are also required
to provide you with this notice regarding our policies and procedures
regarding your Protected Health Information (referred to as "PHI")
and to abide by the terms of this notice, as it may be updated from
time to time. We are permitted to make certain types of uses and
disclosures under applicable law for treatment, payment, and healthcare
operations purposes. For treatment purposes, such uses and disclosures
will take place in providing, coordinating, or managing healthcare
and its related services by one or more of your providers, such
as when your pharmacist consults with your physician or a specialist
regarding your medications, treatment or condition. For payment
purposes, such use and disclosure will take place to obtain or provide
reimbursement for providing pharmaceutical care services, such as
when your case is reviewed to ensure appropriate care was rendered.
For reimbursement purposes, your PHI may be disclosed to one or
several intermediaries employed by your plan sponsor including but
not limited to insurers, pharmacy benefits managers, claims administrators
and computer switching companies. For healthcare operations purposes,
such use and disclosure will take place in a number of ways, including
for quality assessment and improvement, provider review and training,
underwriting activities, reviews and compliance activities; planning,
development, management and administration. Your information could
be used, for example, to assist in the evaluation of the quality
of care you were provided. In addition, we may contact you to provide
refill reminders, health screenings, wellness events, inoculations,
vaccinations or information about treatment alternatives or other
health-related benefits and services that may be of interest to
you. In addition, we may disclose your health information to your
plan sponsor. In addition, we may contact you for the purpose of
fund raising activities, unless you object. We may use and disclose
your PHI, without your authorization, when the pharmacy needs to
contact a physician or physician’s staff and is permitted or required
to do so without individual written consent or authorization. We
may use and disclose your PHI if we are contacted by another pharmacy
who states they have your request and consent to transfer pharmacy
records to them. From time to time, we may employ the services of
business associates who may assist us in one or more tasks and who
may use, change or create PHI. Business associates are required
to comply with all the privacy regulations on your behalf. We may
disclose PHI about you without your authorization to comply with
workers compensation laws, as required by law enforcement, legal
proceedings, public health requirements, health oversight activities
and as required by law. Other uses and disclosures will be made
only with your written authorization, and you may revoke your authorization
at any time by notifying us as described in Section B, except to
the extent the Pharmacy has already taken action in reliance on
a previously signed authorization form. You may ask us to restrict
uses and disclosures of your PHI to carry out treatment, payment,
or healthcare operations, or to restrict uses and disclosures to
family members, relatives, friends or other persons identified by
you who are involved in your care or payment for your care. However,
we are not required to agree to your request. You have the right
to request the following with respect to your PHI: (i) inspection
and copying; (ii) amendment or correction; (iii) an accounting of
the disclosures of this information by us; (We are not required
to account to you for disclosures made for treatment, payment, operations,
disclosures to you, disclosures to your care givers, for notifications
or as otherwise excluded by law); and (iv) receipt of a paper copy
of this notice upon request. The Pharmacy may require patients to
make requests for access to their PHI in writing. In addition, you
may request, and we must accommodate the request, if reasonable,
to receive communications of PHI by alternative means or at alternative
locations. To make this request please contact us as described in
Section B. The Pharmacy may charge for supplies, labor and the postage
involved in preparing PHI for your request. If you desire a price
quote for this service you must request one. You have the right
to withdraw your request of the PHI prior to the delivery. We may
use your name to reference your prescriptions and pharmaceutical
care services. You may be required to sign a signature log form
or to acknowledge receipt of service, to acknowledge receipt of
this notice and the disclosure of PHI as outlined herein. We may
disclose this information to other persons who ask for you or your
prescriptions by name. You may restrict or prohibit these uses and
disclosures by notifying a pharmacy representative orally or in
writing of your restriction or prohibition. We are not required
to honor those requests. If you request our services, we are able
to provide treatment services to you, even if you object to signing
the acknowledgment of the receipt of this notice or if we decide
not to honor a request regarding the information in this document
while noting your requests and refusals in our records. In the event
of an emergency or your incapacity, we will do in our reasonable
judgment what is consistent with your known preference, and what
we determine to be in your best interest. We will inform you of
any such uses or disclosures under such circumstances and give you
an opportunity to object as soon as practicable. We may disclose
to one of your family members, to a relative, to a close personal
friend, or to any other person identified by you, PHI that is directly
relevant to the person’s involvement with your care or payment related
to your care. In addition, unless you object, we may use or disclose
the PHI to notify, identify, or locate a member of your family,
your personal representative, another person responsible for care,
or certain disaster relief agencies of your location, general condition,
or death. If you are incapacitated, there is an emergency, or you
object to this use or disclosure, we will do what in our judgment
is in your best interest regarding such disclosure and will disclose
only the information that is directly relevant to the person’s involvement
with your healthcare. We will also use our judgment and experience
regarding your best interest in allowing people to pick-up filled
prescriptions, or similar forms of PHI. We reserve the right to
change the terms of this notice and to make new notice provisions
effective for all PHI we maintain. You may receive a copy of this
notice by contacting us as outlined in Section B or upon the receipt
of pharmacy care services. If you believe that your privacy rights
have been violated, you may file a complaint with us at the location
described in Section B or to the Secretary of the Department of
Health and Human Services, Hubert H. Humphrey Building, 200 Independence
Ave SW, Washington, DC 20201. You will not be retaliated against
for filing a complaint. Section B: Contacting Us You may contact
us for further information at: Three Lakes Pharmacy Diane Hapka,
Privacy Officer 1790 Superior Street PO Box 437 Three Lakes, WI
54562- 0437 715-546-3266 This notice is effective 3/1/03.
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