THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW THIS NOTICE CAREFULLY.
This Notice of Privacy Practices (“Notice”) describes the privacy practices of PANTHERx® Specialty Pharmacy and its affiliates and subsidiaries. PANTHERx Specialty Pharmacy is required by law to maintain the privacy of Protected Health Information (“PHI”) and to provide individuals with notice of our legal duties and privacy practices with respect to PHI. 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 describes how we may use and disclose PHI about you and your rights regarding the use and disclosure of PHI. Your PHI may be stored electronically and may be disclosed electronically. We are required by law to notify affected individuals following a breach involving unsecured PHI.
We are required to abide by the terms of this Notice currently in effect. We reserve the right to revise or change this Notice and to make any such change applicable to all PHI that we maintain (including PHI obtained before the change). If we change our Notice, we will provide a copy of the revised Notice to you or your representative upon request. We will also post a copy of the current Notice at our pharmacy location(s) and on our Web site at www.pantherxrare.com. You may also obtain a copy of any revised Notice by contacting PANTHERx Specialty Pharmacy’s Privacy Officer.
HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU: We may use and disclose your PHI as described below without your consent or authorization unless otherwise required by applicable law. Not every use or disclosure in a category will be listed. Your PHI may be stored in paper, electronic or other form and may be disclosed electronically and by other methods. We are required to comply with any state laws that impose stricter standards than the uses and disclosures described in this Notice.
- FOR TREATMENT: We may use and disclose PHI about you to provide you with medical treatment, medications, or services and to coordinate your care. For example, we may disclose your PHI to hospitals, physicians, counselors, and any other entity involved in your care. We may use and disclose PHI to contact you by mail, e-mail, or phone to remind you that you have an upcoming prescription due for refill. We may use and disclose PHI to tell you about or recommend possible treatment options or alternatives that may be of interest to you.
- FOR PAYMENT: We may use and disclose PHI about you so that the treatment and services you receive from us may be billed to and payment may be collected from you, an insurance company, or a third party. For example, we may provide information to your health insurance company so that the insurer will reimburse you or us, we may need to obtain prior approval from your insurer for care, and we may use and disclose your health information to determine whether you are eligible for health benefits.
- FOR HEALTH CARE OPERATIONS: We may use and disclose PHI about you for health care operations purposes, including proper administration of records, evaluation of quality of treatment, assessing the care and outcome of your case and others like it, arranging for legal services, and providing appointment reminders. For example, we may use PHI to evaluate the performance of our staff. We also may make disclosures of limited PHI incidental to permitted disclosures.
- FAMILY MEMBERS/DISASTER NOTIFICATION: Unless you object, we may disclose PHI to a family member or other individual who is involved in your medical care or payment for your care. In addition, we may disclose PHI about you to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status, and location.
- AS REQUIRED BY LAW: We may use and disclose your PHI when required to do so by federal, state or local law.
- TO AVERT A SERIOUS THREAT TO HEALTH OR SAFETY: We may use and disclose your PHI if we, in good faith, believe that such disclosure is necessary to prevent or lessen a serious and imminent threat to the health and safety of you, the public, or another person.
- TO BUSINESS ASSOCIATES: We may disclose your PHI to third parties known as “Business Associates” that perform various activities (e.g. legal services, delivery of goods) for us and that agree to protect the privacy of your PHI.
- FOR SPECIFIED GOVERNMENT FUNCTIONS: In certain circumstances, we may use and disclose your PHI for specialized government functions relating to military and veterans, national security and intelligence activities, protective services for the President and others, medical suitability determinations, and inmates or law enforcement custody.
- FOR WORKERS’ COMPENSATION: We may disclose your PHI for workers’ compensation or similar programs.
- FOR PUBLIC HEALTH ACTIVITIES: We may use and disclose PHI about you for public health activities as authorized by law, such as disclosures to prevent or control disease, injury or disability, to report reactions to medications or problems with products, to provide notices of recalls of products, and to report vital statistics, disease information, and similar information to public health authorities.
- TO REPORT ABUSE, NEGLECT OR DOMESTIC VIOLENCE: As authorized by law, we may disclose PHI to government authorities if we believe an individual is the victim of abuse, neglect, or domestic violence and certain conditions are met.
- FOR HEALTH OVERSIGHT ACTIVITIES: We may disclose PHI to a health oversight agency, such as the Department of Health and Human Services, for activities authorized by law. These oversight activities include audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.
- IN CONNECTION WITH LAWSUITS AND ADMINISTRATIVE PROCEEDINGS: We may use and disclose your PHI in response to an order of a court or administrative tribunal. We may also use and disclose your PHI in response to a subpoena, discovery request, or other lawful process, but only when reasonable efforts have been made to notify you about the request or to obtain an order protecting your PHI.
- TO LAW ENFORCEMENT: As authorized by law, we may disclose your PHI to law enforcement officials for certain law enforcement purposes.
- TO CORONERS, MEDICAL EXAMINERS, OR FUNERAL DIRECTORS: We may disclose PHI to coroners, medical examiners, or funeral directors, as authorized by law, prior to and in reasonable anticipation of an individual’s death.
- FOR RESEARCH: We may, under select circumstances, use and disclose your PHI for research.
- FOR ORGAN, EYE OR TISSUE DONATION: We may use and disclose your PHI to organ procurement organizations or other entities engaged in the procurement, banking, or transplantation of organs, eyes, or tissue for the purpose of facilitating the donation and transplantation.
- LIMITED DATA: We may remove most information that identifies you from a set of data and use and disclose this data set for research, public health and health care operations, provided the recipients of the data set agree to keep it confidential.
- HEALTH INFORMATION EXCHANGES: We may participate in one or more Health Information Exchanges (HIEs) and may electronically share your PHI for treatment, payment, healthcare operations and other permitted purposes with other participants in the HIE. HIEs allow your health care providers to efficiently access and use your PHI as necessary for treatment and other lawful purposes.
AUTHORIZATION TO USE OR DISCLOSE PHI: Other uses and disclosures of PHI not described above in this Notice will be made only with a written authorization signed by you or your representative. Subject to compliance with limited exceptions, we will not use or disclose psychotherapy notes, use or disclose your PHI for marketing purposes, or sell your PHI unless you have signed an authorization. If you or your representative authorizes us to use or disclose your PHI, you may revoke that authorization in writing at any time to stop future uses or disclosures. However, your decision to revoke the authorization will not affect or undo any use or disclosure of your PHI that occurred before you notified us of your decision to revoke your authorization.
YOUR RIGHTS REGARDING PHI: You have the following rights regarding PHI we maintain about you. If you have given another individual a medical power of attorney, if another individual is appointed as your legal guardian or if another individual is authorized by law to make health care decisions for you (known as a “personal representative”), that individual may exercise any of the following rights listed below. Please contact the Privacy Officer at the address listed below to obtain the appropriate form to exercise these rights.
- RIGHT TO INSPECT AND COPY: You have the right to inspect and obtain a copy of your PHI that we maintain or direct us to send a copy of your PHI to another person designated by you in writing. In most cases, we will provide this access to you or the person you designate within 30 days of your request. This right applies to PHI used to make decisions about you or payment for your care, subject to limited exceptions. We may charge a reasonable fee for the costs of copying, mailing, and/or other supplies associated with your request. If your PHI is stored electronically and you request an electronic copy, we will provide it to you in a readable electronic format.
- RIGHT TO REQUEST AN AMENDMENT: You have the right to request that we amend our records if you believe that your PHI is incorrect or incomplete. We may deny the request if it is not in writing or does not include a reason for the amendment. We may deny the request for certain other reasons, including that the records are accurate and complete. Requests must be made in writing.
- RIGHT TO AN ACCOUNTING: You have the right to request a list of disclosures of your PHI made by us for certain reasons, including disclosures related to public purposes authorized by law and certain research disclosures. The list will not include disclosures that we are not required to record such as disclosures you authorize. We will provide the first accounting you request during any 12-month period without charge. Additional accounting requests made during the same 12-month period may be subject to a reasonable cost-based fee.
- RIGHT TO REQUEST RESTRICTIONS: You may request restrictions on certain uses and disclosure of your PHI. However, we are not required to agree to your request, except for requests to restrict disclosures to a health plan when you have paid in full out- of-pocket for your care and when the disclosures are not required by law. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment.
- RIGHT TO RECEIVE CONFIDENTIAL COMMUNICATIONS: You have the right to request that we communicate with you through alternative means or locations. We will not request that you provide any reasons for your request and will accommodate your reasonable requests. We may require you to provide information on how payment will be handled and an address or other method to reach you. Requests must be made in writing.
- RIGHT TO RECEIVE A PAPER COPY OF THIS NOTICE: You have the right to a paper copy of this Notice at any time even if you have received this Notice previously electronically. You may obtain a copy by contacting the Privacy Officer or by visiting www.pantherxrare.com.
TO REPORT A CONCERN: If you believe your privacy rights have been violated, you may file a complaint with us or with the Secretary of the Federal Department of Health and Human Services. To file a complaint with us, submit your complaint in writing to our Privacy Officer. You will not be penalized for filing a complaint.
CONTACT PERSON: You may also contact our Privacy Officer if you have questions or comments about our privacy practices or wish to exercise any of your rights described in this Notice. You can reach our Privacy Officer at the following address:
PANTHERx Specialty Pharmacy
Attn: Privacy Officer 24 Summit Park Drive Pittsburgh, PA 15275
Effective Date of this Notice: [Insert effective date]