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.
Effective date: [DATE]. This Notice applies to the protected health information (“PHI”) created or maintained by [PHARMACY LEGAL NAME] and the affiliated licensed providers who furnish care through Baton Rouge Pharmacy.com (together, “we” or “us”). It does not apply to Tennis Friends LLC in its non-clinical website-operator capacity, which is not a covered entity and, where it handles PHI on our behalf, acts as a business associate under a written agreement.
Our Uses and Disclosures Without Your Authorization
Treatment. We use and disclose your PHI to provide and coordinate your care — for example, a provider’s review of your health questionnaire to determine whether an ED medication is appropriate, and sharing your prescription with the dispensing pharmacy.
Payment. We use and disclose PHI to obtain payment for services — for example, processing your payment for a prescriber review or a dispensed medication.
Health care operations. We use and disclose PHI for operations such as quality review, provider oversight, and administering our services.
Business associates. We may share PHI with vendors who perform services for us (for example, hosting, secure-questionnaire, and pharmacy-system providers) under written agreements requiring them to protect it.
As required or permitted by law. We may use or disclose PHI when required by law and for public-health activities, health oversight, judicial and law-enforcement requests that meet legal requirements, to avert a serious threat to health or safety, for workers’ compensation, and similar purposes HIPAA permits.
Uses and Disclosures That Require Your Written Authorization
Most uses and disclosures not described above will be made only with your written authorization, which you may revoke in writing at any time (except to the extent we have already relied on it). Authorization is specifically required for: most uses and disclosures for marketing; any disclosure that is a sale of PHI; and disclosure of psychotherapy notes (which we do not maintain).
Your Rights Regarding Your PHI
You have the right to: inspect and obtain a copy of your PHI (including an electronic copy of electronic records); request an amendment of PHI you believe is incorrect or incomplete; request an accounting of certain disclosures; request restrictions on certain uses and disclosures; request confidential communications by an alternative means or location; obtain a paper copy of this Notice; and be notified of a breach of your unsecured PHI. You also have the right to direct us, in writing, not to disclose to a health plan PHI about a service you paid for in full out of pocket, and we will honor that request except where disclosure is required by law.
To exercise any of these rights, contact our Privacy Officer at [PRIVACY OFFICER NAME/TITLE], midcity@rxtogeaux.com, 12090 S Harrells Ferry Rd, Baton Rouge, LA 70816. We may verify your identity before acting on a request, and some rights are subject to limits under the law.
Our Duties
We are required by law to maintain the privacy of your PHI, to provide this Notice of our legal duties and privacy practices, and to notify affected individuals following a breach of unsecured PHI. We must follow the terms of the Notice currently in effect. We reserve the right to change this Notice and to make the revised Notice effective for PHI we already maintain; a current copy will be posted on the website and available on request.
Complaints
A patient may submit a privacy complaint to the covered entity’s Privacy Officer at the contact above, or with the U.S. Department of Health and Human Services, Office for Civil Rights. Retaliation for filing a good-faith complaint or exercising a HIPAA right is prohibited.