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RALEY’S FAMILY OF FINE STORES
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.
The Pharmacy is required by federal law to maintain the privacy of Protected Health Information (“PHI”), to provide individuals with notice of our legal duties and privacy practices with respect to PHI, and to notify affected individuals if a breach of unsecured PHI occurs. PHI is information that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services. This Notice of Privacy Practices (“Notice”) describes how we may use and disclose PHI to carry out treatment, payment or health care operations and for other specified purposes that are permitted or required by law. The Notice also describes your rights with respect to PHI about you. Some of the uses and disclosures described in this Notice may be limited in certain cases by applicable state laws that are more stringent than the federal standards.
The Pharmacy is required to follow the terms of this Notice. We will not use or disclose PHI about you without your written authorization, except as described in this Notice. We reserve the right to change our practices and this Notice and to make the new Notice effective for all PHI we maintain. Upon request, we will provide any revised Notice to you.
The Forms mentioned in this Notice are available from the Pharmacy or Raley’s Privacy Office. The mailing address of Raley’s Privacy Office is 500 West Capitol Avenue, West Sacramento, CA 95605-2696, and the telephone number is (916) 376-6700 or 1-866-708-5653 (toll free).
Your Health Information Rights
You have the following rights with respect to PHI about you:
Obtain a paper copy of the Notice upon request. You may request a copy of the Notice at any time. Even if you have agreed to receive the Notice electronically, you are still entitled to a paper copy. To obtain a paper copy, contact your Pharmacy or Raley’s Privacy Office.
Request a restriction on certain uses and disclosures of PHI. You have the right to request additional restrictions on our use or disclosure of your PHI by completing and submitting an “Additional Restrictions or Alternative Communications Request” Form to Raley’s Privacy Office. We are not required to agree to those restrictions, except a request by you to restrict disclosure of PHI to a health plan if (i) the disclosure is for the purpose of carrying out payment or health care operations and is not otherwise required by law and (ii) the PHI pertains solely to a health care item or service for which you or someone on your behalf other than the health plan has paid us in full. We will not use or disclose your PHI in violation of any restriction we agree to, other than as required by law, in an emergency or when the information is necessary to treat you.
Inspect and obtain a copy of PHI. You have the right to request access to and a copy of your PHI contained in a designated record set for as long as the Pharmacy maintains the PHI. The designated record set usually will include prescription and billing records. To inspect or request a copy of your PHI, you must complete and submit a “Request for Copy or Access to PHI” Form to Raley’s Privacy Office. We may charge you a fee for the costs of copying, mailing and supplies that are necessary to fulfill your request. We may deny your request to inspect and copy in certain limited circumstances. If you are denied access to your PHI, you may request that the denial be reviewed.
Request an amendment of PHI. If you feel that PHI 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 PHI. To request an amendment, you will be required to complete and submit a “Request to Amend Protected Health Information” Form to Raley’s Privacy Office. You must include a reason that supports your request. In certain cases, we may deny your request for amendment. If we deny your request for amendment, you have the right to file a statement of disagreement with the decision and we may rebutt your statement.
Receive an accounting of disclosures of PHI. You have the right to receive an accounting of the disclosures we have made of your PHI for the six (6) years prior to the date you request the accounting. This right applies to most disclosures that are made for purposes other than treatment, payment, or health care operations. The accounting will exclude certain disclosures, such as disclosures made directly to you, disclosures you authorize, disclosures to friends or family members involved in your care, and disclosures for notification purposes. The right to receive an accounting is subject to certain other exceptions, restrictions, and limitations. To request an accounting, you must complete and submit a “Patient Request for Accounting of Disclosures” Form to Raley’s Privacy Office. Your request must specify the accounting time period, but that time period 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. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time.
Request communications of PHI by alternative means or at alternative locations. For example, you may request that we contact you about medical matters only at your work phone number or at a different residence or post office box. To request confidential communication of your PHI, you must complete and submit an “Additional Restrictions or Alternative Communications Request” Form to Raley’s Privacy Office. We will accommodate all reasonable requests for communicating via alternative means or locations.
Examples of How We May Use and Disclose PHI
The following are descriptions and examples of ways we use and disclose PHI:
Treatment. Examples: Information obtained by the Pharmacy, including information obtained from your doctor, will be used to dispense prescription medications to you. We will document in your record information related to the medications dispensed to you and services provided to you. We may contact, or be contacted by doctors, other pharmacists or other health care providers in order to use or disclose information pertaining to your treatment.
Payment. Examples: We will contact your insurer or pharmacy benefit manager to determine whether it will pay for your prescription and the amount of your copayment. We will bill you or a third-party payor for the cost of prescription medications dispensed to you. The information on or accompanying the bill may include information that identifies you, as well as the prescriptions you are taking.
Health care operations. Examples: The Pharmacy may use information in your health record to monitor the performance of the pharmacists providing you treatment. This information will be used in an effort to continually improve the quality and effectiveness of the health care and service we provide. We may use or disclose PHI on account of the sale, transfer, merger or consolidation of all or part of the Pharmacy.
We are likely to use or disclose PHI for the following purposes:
Business associates: There are some services provided by us through contracts with business associates. Example: We may use a home delivery service to deliver your prescriptions to you at home. When these services are contracted for, we may disclose your PHI to our business associate so that they can perform the job we have asked them to do. To protect your PHI, we require the business associate to sign an agreement that obligates it to appropriately safeguard the PHI.
Communication with individuals involved in your care or payment for your care: Health professionals such as pharmacists, using their professional judgment, may disclose to a family member, other relative, close personal friend or any person you identify, PHI relevant to that person’s involvement in your care or payment related to your care.
Health-related communications: We may contact you to provide refill reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you.
Food and Drug Administration (FDA): We may disclose to the FDA, or persons under the jurisdiction of the FDA, PHI relative to adverse events with respect to drugs, foods, supplements, products and product defects, or post-marketing surveillance information to enable product recalls, repairs, or replacement.
Workers’ compensation: We may disclose your PHI as authorized by and as necessary to comply with laws relating to workers’ compensation or similar programs established by law.
Public health: We may disclose your PHI to public health or legal authorities charged with preventing or controlling disease, injury, or disability.
Law enforcement: We may disclose your PHI for law enforcement purposes as required by law or in response to a valid subpoena or other legal process.
As required by law: We must disclose PHI about you when required to do so by law.
As required by the Secretary of Health and Human Services: We may be required to disclose your PHI to the Secretary of Health and Human Services so that the Secretary may investigate or determine our compliance with Health Insurance Portability and Accountability Act of 1996 (“HIPAA”).
Health oversight activities: We may disclose your PHI to an oversight agency for activities authorized by law. These oversight activities include audits, investigations, and inspections, as necessary for our licensure and for the government to monitor the health care system, government programs, and compliance with civil rights laws.
Judicial and administrative proceedings: If you are involved in a lawsuit or a dispute, we may disclose your PHI in response to a court or administrative order. We may also disclose your PHI in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute.
We are permitted to use or disclose your PHI for the following purposes:
Research: We may disclose your PHI to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your information.
Coroners, medical examiners, and funeral directors: We may release your PHI to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also disclose PHI to funeral directors consistent with applicable law to carry out their duties.
Organ or tissue procurement organizations: Consistent with applicable law, we may disclose your PHI to organ procurement organizations or other entities engaged in the procurement, banking, or transplantation of organs for the purpose of tissue donation and transplant.
Notification: We may use or disclose your PHI to notify or assist in notifying a family member, personal representative, or another person responsible for your care of your location and your general condition.
Correctional institution: If you are or become an inmate of a correctional institution, we may disclose PHI to the institution or its agents when necessary for your health or the health and safety of others.
To avert a serious threat to health or safety: We may use and disclose your PHI when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person.
Military and veterans: If you are a member of the armed forces, we may release your PHI as required by military command authorities. We may also release PHI about foreign military personnel to the appropriate military authority.
National security and intelligence activities: We may release your PHI to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.
Protective services for the President and others: We may disclose your PHI to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state or conduct special investigations.
Victims of abuse, neglect, or domestic violence: We may disclose your PHI to a government authority, such as a social service or protective services agency, if we reasonably believe you are a victim of abuse, neglect, or domestic violence. We will only disclose this type of information to the extent required by law, if you agree to the disclosure, or if the disclosure is allowed by law and we believe it is necessary to prevent serious harm to you or someone else or if the law enforcement or public official that is to receive the report represents that it is necessary and will not be used against you.
Other Uses and Disclosures of PHI
The Pharmacy will obtain your written authorization before using or disclosing PHI about you for purposes other than those provided for above or as otherwise permitted or required by law. Your authorization is required for any use or disclosure of PHI for marketing communications that involve financial remuneration to us or sales of PHI that involve remuneration to us. You may revoke an authorization at any time by submitting a written revocation to the Raley’s Privacy Office. Upon receipt of the written revocation, we will stop using or disclosing PHI about you under the revoked authorization, except to the extent that we have already taken action in reliance on the authorization.
For More Information or to Report a Problem
If you have questions or would like additional information about the Pharmacy’s privacy practices, you may contact the Raley’s Privacy Office at 500 West Capitol Avenue, West Sacramento, CA 95605-2696, (916) 376-6700 (or toll free at 1-866-708-5653). If you believe your privacy rights have been violated, you can file a complaint with the Raley’s Privacy Office or with the Secretary of the U.S. Department of Health and Human Services. There will be no retaliation for filing a complaint. To file a complaint with Raley’s Privacy Office, you may complete and submit a “Privacy Practice Complaint Form” to Raley’s Privacy Office.
This Notice is effective as of September 23, 2013.
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