Notice of Privacy Practices
Notice of Privacy Practices
Pharmacy of Culpeper Privacy Notification
HIPAA 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.
When this Notice of Privacy Practices (“Notice”) refers to “we” or “us,” it is referring to
Pharmacy of Culpeper and all of the pharmacists who provide health care services and the
employees of our pharmacy. We are required by law to maintain the privacy of your protected
health information (“PHI”), to follow the terms of the Notice currently in effect, to give
you this Notice setting forth our legal duties and privacy practices concerning your PHI and
to notify affected individuals following a breach of unsecured PHI. This Notice describes
how we may use and disclose your PHI. Additionally, this Notice explains the rights you have
with respect to your PHI, and certain obligations we must abide by in accordance with the
law. We reserve the right to amend this Notice. If we make any material revisions to this
Notice, we will post a copy of the revised Notice in the pharmacy, on our website and will
offer you a copy of the revised Notice.
USE AND DISCLOSURE OF YOUR PHI – WE WILL USE AND DISCLOSE YOUR PHI FOR TREATMENT, PAYMENT
AND HEALTH CARE OPERATIONS. WE MAY ALSO USE YOUR PHI FOR OTHER PURPOSES THAT ARE PERMITTED
AND/OR REQUIRED BY LAW AND PURSUANT TO YOUR WRITTEN AUTHORIZATION. THE FOLLOWING LISTS
EXAMPLES OF HOW WE MAY USE AND/OR DISCLOSE YOUR PHI. ANY OTHER USES NOT DESCRIBED IN THIS
NOTICE WILL ONLY BE MADE WITH YOUR EXPLICIT WRITTEN AUTHORIZATION, WHICH YOU MAY REVOKE AT
ANY TIME BY PROVIDING US WITH WRITTEN NOTICE OF YOUR REVOCATION.
TREATMENT – WE MAY USE AND DISCLOSE YOUR PHI IN ORDER TO PROVIDE YOU WITH PRESCRIPTION AND
SUPPLY SERVICES. WE MAY DISCLOSE YOUR PHI TO OTHER PHARMACISTS, PHARMACY TECHNICIANS AND
HEALTH CARE PROVIDERS THAT ARE INVOLVED IN YOUR CARE. YOU WILL RECEIVE AN INDIVIDUAL NOTICE
AND HAVE THE OPPORTUNITY TO OPT OUT OF ANY SUBSIDIZED TREATMENT COMMUNICATIONS.
PAYMENT – WE WILL USE AND DISCLOSE YOUR PHI IN ORDER TO OBTAIN PAYMENT FOR THE HEALTH CARE
SERVICES WE PROVIDE TO YOU. WE MAY ALSO NEED TO DISCLOSE YOUR PHI TO RECEIVE PRIOR APPROVAL
FROM YOUR HEALTH PLAN OR TO DETERMINE IF YOUR HEALTH PLAN WILL COVER A CERTAIN PRESCRIPTION
HEALTH CARE OPERATIONS – WE MAY USE AND DISCLOSE YOUR PHI IN CONNECTION WITH THE MANAGEMENT
OF OUR PHARMACY. FOR EXAMPLE, THIS MAY INCLUDE: QUALITY ASSESSMENT AND IMPROVEMENT, INTERNAL
COMPLIANCE AUDITS, AND PERFORMANCE EVALUATIONS. ADDITIONALLY, WE MAY USE YOUR PHI FOR OUR
BUSINESS MANAGEMENT AND GENERAL ADMINISTRATIVE ACTIVITIES.
PRESCRIPTION REFILL REMINDERS, TREATMENT ALTERNATIVES OR HEALTH-RELATED BENEFITS – WE MAY
USE AND DISCLOSE YOUR PHI TO CONTACT YOU TO REMIND YOU ABOUT PRESCRIPTION REFILLS, TO TELL
YOU ABOUT TREATMENT OPTIONS OR ALTERNATIVES, OR TO INFORM YOU ABOUT HEALTH-RELATED BENEFITS
OR SERVICES THAT MAY BE OF INTEREST TO YOU.
FAMILY MEMBERS, RELATIVES OR CLOSE FRIENDS – UNLESS YOU OBJECT TO SUCH DISCLOSURE, WE MAY
DISCLOSE YOUR PHI TO YOUR FAMILY MEMBERS, RELATIVES OR CLOSE PERSONAL FRIENDS, OR ANY OTHER
PERSONS IDENTIFIED BY YOU AS BEING INVOLVED IN THE TREATMENT OR PAYMENT FOR YOUR MEDICAL
CARE. IF YOU ARE NOT PRESENT TO AGREE OR OBJECT TO OUR DISCLOSURE OF YOUR PHI TO A FAMILY
MEMBER, RELATIVE OR FRIEND, WE MAY EXERCISE OUR PROFESSIONAL JUDGMENT TO DETERMINE WHETHER
THE DISCLOSURE IS IN YOUR BEST INTEREST. IF WE DECIDE TO DISCLOSE YOUR PHI, WE WILL ONLY
DISCLOSE THE PHI THAT IS RELEVANT TO YOUR TREATMENT OR PAYMENT.
OTHER PERMITTED AND REQUIRED USES AND DISCLOSURES – WE MAY USE YOUR PHI WITHOUT OBTAINING
YOUR AUTHORIZATION AND WITHOUT OFFERING YOU THE OPPORTUNITY TO AGREE OR OBJECT AS FOLLOWS:
as required by law, provided however, that the use or disclosure will be made in compliance
with applicable law;
to a public health authority that is authorized by law to collect or receive such
information, or to a foreign government agency that is acting in collaboration with a public
health authority and these health activities generally include preventing or controlling
disease, reporting deaths, reporting adverse effects of medications or problems with
products, notification of communicable disease, and reporting abuse or neglect under certain
to a health oversight agency for oversight activities authorized by law, including audits
and inspections, and civil, administrative or criminal investigations, proceedings or
for judicial or administrative proceedings purposes in response to a subpoena, court order,
discovery request, etc. but only if efforts have been made to inform you about the request
or to obtain an order protecting the information requested;
to law enforcement to report certain injuries, comply with court orders or warrants or
similar process, to identify a suspect, fugitive, missing person or victim or to report a
to a coroner or medical examiner to perform duties authorized by law such as identification
of a deceased person or determining the cause of death;
to funeral directors, consistent with applicable law, as necessary to carry out their
to organ procurement organizations or similar entities for the purpose of facilitating
organ, eye or tissue donation and transplantation;
for research purposes provided that certain approvals take place and assurances are given;
to avert a serious threat to health or safety, so long as the disclosure is only to a person
who is reasonably able to prevent or lessen such threat;
for military and veterans activities (including foreign military personnel) to assure the
proper execution of a military mission and to determine eligibility for benefits;
for national security and intelligence activities for the purpose of conducting lawful
intelligence, counter-intelligence and other national security activities;
for protection of the President and other authorized persons or foreign heads of state or to
conduct authorized investigations;
to a correctional institution or law enforcement custodian if you are an inmate or under
to the extent necessary to comply with laws relating to workers compensation and work-
YOUR RIGHTS AS OUR PATIENT – AS OUR PATIENT, YOU HAVE A NUMBER OF RIGHTS ASSOCIATED WITH
YOUR PHI. THE FOLLOWING DESCRIBES YOUR SPECIFIC RIGHTS.
YOU HAVE THE RIGHT TO REQUEST RESTRICTIONS OR LIMITATIONS ON HOW WE USE AND/OR DISCLOSE YOUR
PHI, HOWEVER, WE DO NOT HAVE TO AGREE TO YOUR REQUESTED RESTRICTION OR LIMITATION (EXCEPT
FOR TRANSACTIONS YOU PAID FOR IN FULL OUT-OF-POCKET). YOUR WRITTEN REQUEST MUST SPECIFY: (1)
IF YOU WOULD LIKE TO RESTRICT OR LIMIT OUR USE AND/OR DISCLOSURE; (2) WHAT INFORMATION YOU
WANT RESTRICTED OR LIMITED; AND (3) TO WHOM THE RESTRICTION OR LIMITATION APPLIES (E.G.,
SPOUSE). If we agree to your request, it will not prevent us from disclosing your PHI as
follows: (1) to you if you request access or an accounting of disclosures; (2) for purposes
required or permitted by law; or (3) in case of an emergency.
YOU HAVE THE RIGHT TO RECEIVE CONFIDENTIAL COMMUNICATIONS CONCERNING YOUR PHI BY ALTERNATIVE
MEANS OR VIA ALTERNATIVE LOCATIONS. FOR EXAMPLE, YOU MAY WANT TO RECEIVE COMMUNICATIONS
RELATED TO YOUR PRESCRIPTIONS AT A DIFFERENT ADDRESS OTHER THAN YOUR HOME ADDRESS. IF YOU
WISH TO RECEIVE CONFIDENTIAL COMMUNICATIONS VIA ALTERNATIVE MEANS OR LOCATIONS, PLEASE
SUBMIT YOUR REQUEST IN WRITING TO THE PRIVACY OFFICER AND SET FORTH THE ALTERNATIVE MEANS BY
WHICH YOU WISH TO RECEIVE COMMUNICATIONS OR THE ALTERNATIVE LOCATION AT WHICH YOU WISH TO
RECEIVE SUCH COMMUNICATIONS. WE WILL ACCOMMODATE ALL REASONABLE REQUESTS.
YOU HAVE THE RIGHT TO ACCESS, INSPECT AND OBTAIN A COPY OF YOUR PHI, INCLUDING ANY
ELECTRONIC PHI; PROVIDED, HOWEVER, YOU ARE NOT ENTITLED TO ACCESS CERTAIN PHI EXEMPTED UNDER
HIPAA. TO THE EXTENT WE MAINTAIN ELECTRONIC PHI, UPON REQUEST WE WILL PROVIDE YOU WITH A
COPY OF YOUR PHI IN THE FORMAT REQUESTED. IF WE DO NOT HAVE YOUR PHI IN OUR POSSESSION, WE
WILL PROVIDE YOU WITH THE APPROPRIATE CONTACT INFORMATION WHEN YOUR REQUEST IS RECEIVED. IF
YOU REQUEST A COPY OF YOUR PHI, YOU WILL RECEIVE A RESPONSE TO YOUR REQUEST IN A TIMELY
FASHION BUT MAY BE CHARGED A REASONABLE, COST-BASED FEE TO COVER COPY COSTS AND POSTAGE. IN
SOME LIMITED CIRCUMSTANCES, WE MAY DENY YOUR REQUEST FOR ACCESS TO PHI IN WHICH CASE YOU MAY
REQUEST FOR THE DENIAL TO BE REVIEWED. IF ACCESS IS ULTIMATELY DENIED, YOU ARE ENTITLED TO A
WRITTEN EXPLANATION WITH THE REASON(S) FOR THE DENIAL.
YOU HAVE THE RIGHT TO RECEIVE AN ACCOUNTING OF DISCLOSURES OF YOUR PHI MADE BY US, INCLUDING
DISCLOSURES TO OR BY OUR BUSINESS ASSOCIATE(S), FOR A PERIOD OF SIX (6) YEARS PRIOR TO THE
DATE ON WHICH YOU REQUEST AN ACCOUNTING OF DISCLOSURES, OR SUCH LESSER PERIOD AS YOU
INDICATE. YOU WILL RECEIVE ONE REQUEST ANNUALLY FREE OF CHARGE AND, THEREAFTER, WE MAY
CHARGE YOU A REASONABLE, COST-BASED FEE FOR EACH SUBSEQUENT REQUEST FOR AN ACCOUNTING OF
DISCLOSURES WITHIN THE SAME TWELVE-MONTH PERIOD. WE WILL NOTIFY YOU OF THE COST FOR AN
ACCOUNTING OF DISCLOSURES AND YOU MAY CHOOSE TO WITHDRAW OR MODIFY YOUR REQUEST BEFORE WE
IF YOU BELIEVE WE HAVE PHI ABOUT YOU THAT IS INCORRECT OR INCOMPLETE, YOU MAY MAKE A WRITTEN
REQUEST TO US STATING THE REASONS TO SUPPORT ANY REQUESTED AMENDMENT. YOU HAVE THE RIGHT TO
REQUEST AN AMENDMENT TO YOUR PHI FOR SO LONG AS WE MAINTAIN YOUR PHI. IF WE DO NOT HAVE YOUR
PHI IN OUR POSSESSION, WE WILL PROVIDE YOU WITH THE APPROPRIATE CONTACT INFORMATION WHEN WE
RECEIVE YOUR REQUEST. WE WILL RESPOND TO YOUR REQUEST FOR AN AMENDMENT AFTER WE RECEIVE YOUR
REQUEST. HOWEVER, WE MAY DENY YOUR REQUEST FOR AMENDMENT IF, FOR EXAMPLE, WE DETERMINE THAT
THE PHI YOU REQUESTED WAS NOT CREATED BY US OR IS ALREADY ACCURATE AND COMPLETE. YOU MAY
RESPOND TO OUR DENIAL BY FILING A WRITTEN STATEMENT OF DISAGREEMENT, BUT WE HAVE THE RIGHT
TO REBUT YOUR DISAGREEMENT. IF THIS OCCURS, YOU HAVE THE RIGHT TO REQUEST THAT YOUR ORIGINAL
REQUEST, OUR DENIAL, YOUR STATEMENT OF DISAGREEMENT, AND OUR REBUTTAL BE INCLUDED IN FUTURE
DISCLOSURES OF YOUR PHI.
YOU HAVE THE RIGHT AT ANY TIME TO OBTAIN A PAPER COPY OF THIS NOTICE, EVEN IF YOU RECEIVE
THIS NOTICE ELECTRONICALLY. IF YOU HAVE RECEIVED AN ELECTRONIC COPY OF THIS NOTICE, BUT WISH
TO OBTAIN A PAPER COPY OF THIS NOTICE, PLEASE SEND YOUR REQUEST IN WRITING TO THE PRIVACY
OFFICER AT THE ADDRESS LISTED BELOW.
YOU HAVE THE RIGHT TO OPT-OUT OF FUNDRAISING AND YOUR PHI WILL NOT BE USED FOR FUNDRAISING
PURPOSES OR SOLD WITHOUT YOUR PRIOR AUTHORIZATION.
ADDITIONAL INFORMATION/QUESTIONS OR COMPLAINTS
IF YOU NEED ANY ADDITIONAL INFORMATION ABOUT THIS NOTICE OR WISH TO EXERCISE ANY OF YOUR
RIGHTS SET FORTH IN THIS NOTICE, PLEASE CONTACT THE PRIVACY OFFICER AT THE FOLLOWING
ADDRESS: DAN’S PHARMACY, 418 GARRISONVILLE RD STE 100 STAFFORD, VA 22554
IF YOU BELIEVE YOUR PRIVACY RIGHTS HAVE BEEN VIOLATED, YOU MAY FILE A COMPLAINT WITH US OR
WITH THE SECRETARY OF THE DEPARTMENT OF HEALTH AND HUMAN SERVICES WITHOUT RETALIATION.
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