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.
WellDyneRx, LLC (Provider) is required by law to maintain the privacy of protected health information, to provide individuals with notice of its legal duties and privacy practices with respect to protected health information, and to notify affected individuals following a breach of unsecured protected health information. Provider is required to follow the terms of the notice of privacy practices (Notice) which is currently in effect. Provider reserves the right to change the terms of this Notice, the practices described within this Notice, and to make the Notice effective for any protected health information maintained by Provider.
Uses and Disclosures of Protected Health Information. Protected health information includes demographic and medical information that concerns the past, present, or future physical or mental health of an individual. Demographic information could include your name, address, telephone number, social security number and any other means of identifying you as a specific person. Protected health information contains specific information that identifies a person or can be used to identify a person.
Protected health information is health information created or received by a health care provider, health plan, employer, or health care clearinghouse. Provider may act as each of the above business types. Protected health information is used by Provider in many ways while performing normal business activities. Your protected health information may be used or disclosed by Provider for purposes of treatment, payment and health care operations.
The following are additional descriptions and examples of ways Provider may use and disclose your protected health information:
Provider will use protected health information for treatment. Example: Information obtained by a pharmacist may be used to dispense prescription medications to you, contact prescribers and counsel you and other caregivers.
Provider may document in your record, information related to the medications dispensed to you and services provided to you. Provider may use protected health information to coordinate care with other pharmacies and healthcare providers. For example, Provider may use protected health information to coordinate care with other pharmacies and healthcare providers if Provider has concerns regarding suspected prescription misuse or addiction.
Provider will use protected health information for payment. Example: Provider may contact your insurer, pharmacy benefit manager, or other entity involved in payment, to determine whether it will pay for your prescription and the amount of your copayment.
Provider will bill you or a third-party payer for the cost of prescription medications dispensed to you. The information on or accompanying the bill may include information that identifies you, and the prescriptions you are taking. Provider will give the insurer the information they need to perform their duties under their contract with your plan sponsor.
Provider will use protected health information for health care operations. Example: The Provider may use information in your health record to monitor the performance of the pharmacists providing treatment to you. Health care operations include activities such as training, legal, auditing and compliance, customer service and other management and administration. Protected health information may be transferred to another healthcare provider.
Provider may also use or disclose protected health information without authorization as allowed by law. Examples may include:
Business associates: There are some services provided by Provider through contracts with business associates. Examples include liability insurers, attorneys, data conversion processors, collection agencies, software and systems providers, and data switches to relay data to your insurer and other similar associates. When these services are provided through a contract, Provider may disclose protected health information about you to Provider’s business associates so they can perform the job Provider has asked them to do; to protect protected health information about you, and provide protected health information.
Communication with individuals involved in your care or payment for your care: Health professionals such as pharmacists and other Provider employees, using their professional judgment, may disclose protected health information to a person that has been designated by you and/or is acting as your “agent” or authorized representative, as permitted under state law. Provider may disclose protected health information relevant to that person’s involvement in your care, or payment related to your care. For example Provider may disclose protected health information to a person designated by you to order a prescription.
Health-related communications: Provider may contact you to provide refill reminders, information about treatment alternatives or other health-related benefits and services that may be of interest to you. This communication may be via phone, mail, e-mail or other form of communication.
Food and Drug Administration (FDA): Provider may disclose to the FDA, or persons under the jurisdiction of the FDA, protected health information 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.
Worker’s compensation: Provider may disclose protected health information about you as authorized by and as necessary to comply with state laws relating to worker’s compensation or similar programs.
Public health: As required by law, Provider may disclose protected health information about you to public health or legal authorities charged with preventing or controlling disease, injury, or disability.
Law enforcement: Provider may disclose protected health information about you for law enforcement purposes as specifically required or permitted by law, including disclosures to an inspector or investigator whose duty it is to enforce the laws relating to drugs, and who is engaged in a specific investigation involving a designated person or drug, or for reporting suspected crimes such as child abuse.
As required by law: Provider must disclose protected health information about you when required to do so by law.
Health oversight activities: Provider may disclose protected health information about you to an oversight agency for activities authorized by law. These oversight activities include audits, investigations and inspections, as necessary for Provider’s 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, Provider may disclose protected health information about you in response to a valid court or administrative order or warrant or grand jury subpoena. Provider is permitted to use or disclose protected health information about you for the following purposes:
Research: Provider may disclose protected health information about you to researchers when their research has been approved by an institutional review board or a privacy board and established protocols to ensure the privacy of your information.
Coroners, medical examiners and funeral directors: Provider may release protected health information about you to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. Provider may also disclose protected health information to funeral directors consistent with applicable law to carry out their duties.
Organ or tissue procurement organizations: Consistent with applicable law, Provider may disclose protected health information about you to organ procurement organizations or other entities engaged in the procurement, banking, or transplantation of organs for the purpose of tissue donation and transplant.
Fundraising: Provider may contact you as part of a fundraising effort on behalf of Provider. If you are contacted as part of a fundraising effort you may opt-out of receiving such communications.
Plan Sponsor. In the event Provider is acting as, or is authorized to act on the behalf of, a group health plan or a health insurance issuer, or HMO, Provider may disclose protected health information to the sponsor of the Plan.
Correctional institution: If you are or become an inmate of a correctional institution, Provider may disclose protected health information 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: Provider may use and disclose protected health information about you when necessary to prevent a serious threat to your health and safety, or the health and safety of the public or another person, but generally will do so only with your written consent unless Provider is authorized by law to make the disclosure. For example, Provider will disclose the information in situations where state law provides that the pharmacist has a “duty to warn” about a specific threat or danger.
Military and veterans: If you are a member of the armed forces, Provider will release protected health information about you as required by military command authorities if required to do so by law. Provider may also release protected health information about foreign military personnel to the appropriate military authority, if required to do so by law. If not required to do so by law, Provider will obtain your written consent prior to making such disclosures.
National security and intelligence activities: Provider may release protected health information about you to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.
Protective services for the President and others: Provider may disclose protected health information about you 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: Provider may disclose protected health information about you to a government authority, such as a social service or protective services agency, if Provider reasonably believes you are a victim of abuse, neglect, or domestic violence. Provider will only disclose this type of information to the extent required by law.
Other Uses and Disclosures. Provider will obtain your written authorization before using or disclosing your protected health information for a purpose not described or referenced in this Notice (or as otherwise permitted or required by law). A written authorization may include an expiration date and may be revoked by you in writing at any time.
Individual Rights. You have the following rights with respect to your protected health information:
Request Restriction. You have the right to make a request to Provider for additional restrictions on the use or disclosure of your protected health information. For example, you may request a limitation of use or disclosure of protected health information to individuals involved in your care. Provider is not required to agree to any limitation/restriction.
Right to Receive. You have the right to make a request to Provider to communicate with you about medical matters in a certain way or at a certain location. For example, you may ask that Provider contact you at home or only through telecommunications.
Right to Inspect. You have the right to receive and inspect copies of your protected health information contained in a designated record set for so long as Provider maintains the protected health information. In order to receive and inspect copies of your protected health information you must send a written request to Provider. Provider may charge you fees associated with the costs of retrieving, copying, and delivering your protected health information to the extent permitted by law. Provider may deny your request to inspect and copy your protected health information in certain cases. In the event Provider denies your request to inspect and copy your protected health information, you may request that the denial be reviewed.
Right to Amend. You have the right to make a request for an amendment if you feel protected health information about you is incomplete or inaccurate. You may request an amendment for so long as Provider maintains your protected health information. In order to request an amendment, you must send Provider a written request, including the reason for your request. Provider may deny your request to amend your protected health information in certain cases. In the event Provider denies your request to amend your protected health information, you may file a statement of disagreement and Provider may provide a response to that statement.
Right to an Accounting of Disclosures. You have the right to receive a list of certain disclosures Provider has made of your protected health information, subject to certain restrictions, limitations, and exceptions. You may not request an accounting of disclosures for more than a six (6) year period from the date of your request. You may not request an accounting of disclosures prior to April 14th 2003. An accounting of disclosures will not include certain disclosures, which have been made to you, to individuals involved with your care, other disclosures authorized by you, disclosures made to carry out treatment, payment, or healthcare operations, disclosures in furtherance of the public health, disclosures made to regulatory authorities and disclosures made related to abuse, neglect or domestic violence. The first accounting of disclosures made by you within a twelve (12) month period will be free of charge, but you may be charged for the cost of additional requests.
Right to Paper Notice of Privacy Practices. You have the right to a paper copy of this Notice. You may ask Provider for a copy of this Notice at any time. Even if you have agreed to receive this Notice electronically, you are still entitled to a paper copy of the current Notice in effect.
Complaints. If you believe your privacy rights have been violated, you can file a complaint. If you file a complaint, no retaliation will be taken against you. A complaint must be in writing and addressed to:
ATTN: Privacy Officer
500 Eagles Landing Drive
Lakeland, FL 33810
You may also file a complaint with the Secretary of Health and Human Services.
Effective Date. This Notice is effective beginning September 22 2014, and shall be in effect until a new Notice is approved and posted.
888-479-2000 | www.WellDyneRx.com