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.
*Protected Health Information (PHI)
PLEASE REVIEW IT CAREFULLY
Notice Effective Date: December 1, 2010
Axline Pharmacy is required by state and federal law to maintain the privacy of your protected health information (PHI). PHI includes any identifiable information about your physical or mental health, the health care you receive, and the payment for your health care.
Axline Pharmacy is required by law to provide you with this notice to tell you how it may use and disclose your PHI and to inform you of your privacy rights. Axline Pharmacy must follow the privacy practices as set forth in its most current Notice of Privacy Practices.
This notice refers only to the use/disclosure of PHI. It does not change existing law, regulations and policies regarding informed consent for treatment.
Changes to this Notice
Axline Pharmacy may change its privacy practices and the terms of this notice at any time. Changes will apply to PHI that Axline Pharmacy already has as well as PHI that Axline Pharmacy receives in the future. The most current privacy notice will be available on request. Every privacy notice will be dated.
How Does Axline Pharmacy Use and Disclose PHI?
Axline Pharmacy may use/disclose your PHI for treatment, payment and health care operations without your authorization. Otherwise, your written authorization is needed unless an exception listed in this notice applies.
Uses/Disclosures Relating to Treatment, Payment and Health Care Operations
The following examples describe some, but not all, of the uses/disclosures that are made for treatment, payment and health care operations.
For treatment - Consistent with its regulations and policies, Axline Pharmacy may use/disclose PHI to doctors, nurses, service providers and other personnel (e.g., interpreters), who are involved in delivering your health care and related services. Your PHI will be used to assist in developing your treatment and/or service plan and to conduct periodic reviews and assessments. PHI may be shared with other health care professionals and providers to obtain prescriptions, lab work, consultations and other items needed for your care. PHI will be shared with Axline Pharmacy service providers for the purposes of referring you for Axline Pharmacy services and then for coordinating and providing the Axline Pharmacy services you receive.
To obtain payment - Consistent with the restrictions set forth in its regulations and policies, Axline Pharmacy may use/disclose your PHI to bill and collect payment for your health care services. Axline Pharmacy may release portions of your PHI to the Medicaid or Medicare program or a third party payor to determine if they will make payment, to get prior approval and to support any claim or bill.
For health care operations - Axline Pharmacy may use/disclose PHI to support activities such as program planning, management and administrative activities, quality assurance, receiving and responding to complaints, compliance programs (e.g., Medicare), audits, training and credentialing of health care professionals, and certification and accreditation (e.g., The Joint Commission).
Axline Pharmacy may use PHI to remind you of an appointment or to provide you with information about treatment alternatives or other health related benefits and services that may be of interest to you e.g., deliver reminders.
Uses/Disclosures Requiring Authorization
Axline Pharmacy is required to have a written authorization from you or your personal representative with the legal authority to make health care decisions on your behalf for uses/disclosures beyond treatment, payment and health care operations unless an exception listed below applies. You may cancel an authorization at any time, if you do so in writing. A cancellation will stop future uses/disclosures except to the extent Axline Pharmacy has already acted based upon your authorization.
- For guardianship or commitment proceedings when Axline Pharmacy is a party
- For judicial proceedings if certain criteria are met
- For protection of victims of abuse or neglect
- For research purposes, following strict internal review
- To correctional institutions, if you are an inmate
- For federal and state oversight activities such as fraud investigations, usual incident reporting, and protection and advocacy activities
- If required by law, or for law enforcement or national security
- To avoid a serious and imminent threat to public health or safety
- For public health activities such as tracking diseases and reporting vital statistics
You, or a personal representative with legal authority to make health care decisions on your behalf, have the right to:
- Request that Axline Pharmacy use a specific address or telephone number to contact you. Axline Pharmacy is not required to comply with your request.
- Obtain, upon request, a paper copy of this notice or any revision of this notice, even if you agreed to receive it electronically.
- *Inspect and copy PHI that may be used to make decisions about your care. Access to your records may be restricted in limited circumstances. If you are denied access, in certain circumstances, you may request that the denial be reviewed. Fees may be charged for copying and mailing.
- *Request additions or corrections to your PHI. Axline Pharmacy is not required to comply with a request. If it does not comply with your request, you have certain rights.
- *Receive a list of individuals who received your PHI from Axline Pharmacy (excluding disclosures that you authorized or approved, disclosures made for treatment, payment and healthcare operations and some required disclosures).
- *Ask that Axline Pharmacy restrict how it uses or discloses your PHI. Axline Pharmacy is not required to agree to a restriction.
* These requests must be made in writing
Your individual records relating to Axline Pharmacy provided care and services will be retained at a minimum for 7 years from the date of service. After that time, your records may be destroyed.
To Contact Axline Pharmacy or to File a Complaint
If you want to obtain further information about Axline Pharmacy privacy practices, or if you want to exercise your rights, or you feel your privacy rights have been violated, or you want to file a complaint, you may contact: Axline Pharmacy Operations Manager, PO Box 1087, Bloomington, IL 61702-1087
Phone: (309) 828-6767, Fax: (309) 828-6970. A complaint must be made in writing.
No one may retaliate against you for filing a complaint or for exercising your rights as described in this notice.
You also may file a complaint with the Secretary of Health and Human Services, Office for Civil Rights, U.S. Department of Health and Human Services, JFK Federal Building, Room 1875, Boston, MA. 02222