ASSISTED LIVING PHARMACY SERVICE, LLC PHONE: 414-433-1700 FAX: 414-433-1730
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. USE AND DISCLOSURE OF HEALTH INFORMATION
Assisted Living Pharmacy Service, LLC (“ALPS”) may use your health information, that is, information that constitutes protected health information as defined in the Privacy Rule of the Administrative Simplification provisions of the Health Insurance Portability and Accountability Act of 1996, for purposes of providing you treatment, obtaining payment for your care, and conducting health care operations. Assisted Living Pharmacy Service has established a policy to guard against unnecessary disclosure of your health information.
THE FOLLOWING IS A SUMMARY OF THE CIRCUMSTANCES UNDER WHICH AND PURPOSES FOR WHICH YOUR HEALTH INFORMATION MAY BE USED AND DISCLOSED:
To Provide Treatment. Assisted Living Pharmacy Service may use your health information to provide care to you and disclose your health information to others who provide care to you. For example, physicians involved in your care will need information about your symptoms in order to prescribe appropriate medications. Assisted Living Pharmacy Service also may disclose your health care information to individuals outside of ALPS involved in your care, including family members, pharmacists, suppliers of medical equipment, or other health care professionals. To Obtain Payment. Assisted Living Pharmacy Service may include your health information in invoices to collect payment from third parties for the care you may receive from ALPS. For example, ALPS may be required by your health insurer to provide information regarding your health care status so that the insurer will reimburse you or ALPS. Assisted Living Pharmacy Service may need to obtain prior approval from your insurer and may need to explain to the insurer your need for health care and the services that will be provided to you. When Legally Required. Assisted Living Pharmacy Service will disclose your health information when it is required to do so by any Federal, State, or local law. To Conduct Health Oversight Activities. Assisted Living Pharmacy Service may disclose your health information to a health oversight agency for activities including: audits; civil, administrative or criminal investigations; inspections; licensure or disciplinary action. Assisted Living Pharmacy Service, however, may not disclose your health information if you are the subject of an investigation and the investigation does not arise out of and is not directly related to your receipt of health care or public benefits. In Connection With Judicial and Administrative Proceedings. As permitted or required by state law, ALPS may disclose your health information in the course of any judicial or administrative proceeding in response to an order of a court or administrative tribunal as expressly authorized by such order or in response to a subpoena, discovery request, or other lawful process. Reasonable efforts will be made to either notify you about the request or to obtain an order protecting your health information. For Law Enforcement Purposes. As permitted or required by State law, ALPS may disclose your health information to a law enforcement official for certain law enforcement purposes, including, under certain limited circumstances, if you are a victim of a crime or in order to report a crime. For Specified Government Functions. In certain circumstances, the Federal regulations authorize ALPS to use or disclose your health information to facilitate specified government functions relating to the military and veterans, national security, and intelligence activities, protective services for the President and others, medical suitability determinations, and inmates and law enforcement custody. For Worker’s Compensation. Assisted Living Pharmacy Service may release your health information for Worker’s Compensation or similar programs.
AUTHORIZATION TO USE OR DISCLOSE HEALTH INFORMATION
Other than is stated above, Assisted Living Pharmacy Service will not disclose your health information other than with your written authorization. If you or your representative authorizes Assisted Living Pharmacy Service to use or disclose your health information, you may revoke that authorization in writing at any time.
YOUR RIGHTS WITH RESPECT TO YOUR HEALTH INFORMATION
You have the following rights regarding your health information that Assisted Living Pharmacy Service maintains: Right to Request Restrictions. You may request restrictions on certain uses and disclosures of your health information. You have the right to request a limit on ALPS’s disclosure of your health information to someone who is involved in your care or the payment of your care. However, ALPS is not required to agree to your request. If you with to make a request for restrictions, please contact Mary Beth Newhouse at 414-433-1700. Right to Receive Confidential Communications. You have the right to request that ALPS communicate with you in a certain way. For example, you may ask that ALPS only conduct communications pertaining to your health information with you privately with no other family members present. If you wish to receive confidential communications, please contact Mary Beth Newhouse at 414-433-1700. Assisted Living Pharmacy Service will not request that you provide any reasons for your request and will attempt to honor your reasonable request for confidential communications. Right to Inspect and Copy Your Health Information. You have the right to inspect and copy your health information, including billing records. A request to inspect and copy records containing your health information may be made to Mary Beth Newhouse at 414-433-1700. If you request a copy of your health information, ALPS may charge a reasonable fee for copying and assembling costs associated with your request. Right to Amend Your Health Information. You or your representative has the right to request that ALPS amend your records if you believe your health information records are incorrect or incomplete. That request may be made as long as the information is maintained by ALPS. A request for an amendment of records must be made in writing to Mary Beth Newhouse, 1441 North Mayfair Road, Suite 202, Wauwatosa, WI 53226. Assisted Living Pharmacy Service may deny the request if it is not in writing or does not include a reason for the amendment. The request also may be denied if your health information records were not created by ALPS, if the records you are requesting are not part of ALPS’s records, if the health information you wish to amend is not part of the health information you or your representative are permitted to inspect and copy, or if, in the opinion of ALPS, the records containing your health information are accurate and complete. Right to an Accounting. You or your representative has the right to request an accounting of disclosures of your health information made by ALPS for certain purposes, which may include disclosures authorized by law and disclosures made for research. The request for an accounting must be made in writing to Mary Beth Newhouse, 1441 North Mayfair Road, Suite 202, Wauwatosa, WI 53226. The request should specify the time period for the accounting starting on April 1, 2004. Accounting requests may not be made for periods of time in excess of six (6) years. Assisted Living Pharmacy Service will provide the first accounting you request during any 12-month period without charge. Subsequent accounting requests may be subject to a reasonable cost-based fee. Right to a Paper Copy of this Notice. You or your representative has a right to a separate paper copy of this Notice at any time, even if you or your representative has received this Notice previously. To obtain a separate paper copy, please contact Mary Beth Newhouse, 414-433-1700.
DUTIES OF ASSISTED LIVING PHARMACY SERVICES
Assisted Living Pharmacy Service is required by law to maintain the privacy of your health information and to provide to you and your representative this Notice of its duties and privacy practices. ALPS is required to abide by the terms this Notice as may be amended from time to time. Assisted Living Pharmacy Service reserves the right to change the terms of its Notice and to make the new Notice provisions effective for all health information that it maintains. If ALPS makes a material change to this Notice, ALPS will provide a copy of the revised Notice to you or your representative. You or your representative has the right to express complaints to ALPS and to the Secretary of Health and Human Services if you or your representative believes that your privacy rights have been violated. Any complaints to ALPS should be made in writing to Mary Beth Newhouse, 1441 North Mayfair Road, Suite 202, Wauwatosa, WI 53226. Assisted Living Pharmacy Service encourages you to express any concerns that you may have regarding the privacy of your information. You will not be retaliated against in any way for filing a complaint. CONTACT PERSON Assisted Living Pharmacy Service has designated Mary Beth Newhouse as its contact person for all issues regarding patient privacy and your rights under the Federal privacy standards. You may contact this person at 1441 North Mayfair Road, Suite 202, Wauwatosa, WI 53226 or at 414-433-1700.
This Notice is effective April 1, 2004.
IF YOU HAVE ANY QUESTIONS REGARDING THIS NOTICE, PLEASE CONTACT
Mary Beth Newhouse at 414-433-1700 or at 1441 North Mayfair Road, Suite 202, Wauwatosa, WI 53226.