HIPAA NOTICE OF PRIVACY PRACTICES
Effective Date: July 10, 2013
Written complaints, written revocation of authorization to use or disclose PHI, written requests for a copy of your PHI, amendment to your PHI, an accounting of disclosures, restrictions on your PHI or for confidential communications may be mailed to:
Attn: Privacy Officer
Fidelis Specialty Pharmacy
5275 Arville Street
Las Vegas, NV 89118
Please include your name, address, and date of birth.
We reserve the right to revise this Notice. A revised Notice will be effective for PHI we already have about you, as well as any PHI we may receive in the future. We will communicate revisions to this Notice through our website at www.fidelis-rx.com/HIPAA
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.
This Notice of Privacy Practices (“Notice”) describes:
• How we may use and disclose your protected health information (“PHI”)
• Your rights to access and amend your PHI
We are required by law to:
• Maintain the privacy of your PHI
• Provide you with notice of our legal duties and privacy practices with respect to PHI
• Abide by the terms of the Notice currently in effect for Fidelis Specialty Pharmacy
PERMITTED USES AND DISCLOSURES OF YOUR PHI
We may use and disclose your PHI for the following purposes.
• Treatment: We may use and disclose your PHI to healthcare professionals or other third parties to provide, coordinate and manage the delivery of health care. For example, your pharmacist may disclose PHI about you to your doctor in order to coordinate the prescribing and delivery of your drugs. We also may provide you with treatment reminders and information about potential side effects, drug interactions and other treatment related issues involving your medicine.
• Payment: We may use and disclose PHI about you to receive payment for our services, manage your account, fulfill our responsibilities under your benefit plan, and process your claims for drugs you have received. For example, we may give PHI to your health plan (or its designee) so we can confirm your eligibility for pharmacy benefits, or we may submit claims to your health plan, employer or other third party for payment.
• Healthcare Operations: We may use and disclose your PHI to carry on our own business planning and administrative operations. We need to do this so we can provide you with high-quality services. For example, we may use and disclose PHI about you to assess the use or effectiveness of certain drugs, develop and monitor medical protocols, and to provide information regarding helpful health-management services.
• Information that May Be of Interest to You: We may use or disclose your PHI to contact you about treatment options or alternatives that may be of interest to you. For example, we may call you to remind you of expired prescriptions, the availability of alternative drugs, or to inform you of other products that may benefit your health.
• Individuals Involved in Your Care or Payment for Your Care: We may disclose PHI about you to someone who assists in or pays for your care. Unless you write to us and specifically tell us not to, we may disclose your PHI to someone who has your permission to act on your behalf. We will require this person to provide adequate proof that he or she has your permission.
• Parents or Legal Guardians: If you are a minor or under a legal guardianship, we may release your PHI to your parents or legal guardians when we are permitted or required under federal and applicable state law.
• Business Associates: We arrange to provide some services through contracts with business associates so that they may help us operate more efficiently. We may disclose your PHI to business associates acting on our behalf. If any PHI is disclosed, we will protect your information from unauthorized use and disclosure using confidentiality agreements. Our business associates may, in turn, use vendors to assist them in providing services to us. If so, the business associates must enter into a confidentiality agreement with the vendor, which protects your information from unauthorized use and disclosure
• Research: Under certain circumstances, we may use and disclose PHI about you for research purposes. Before we use or disclose PHI about you, we will either remove information that personally identifies you, obtain your written authorization, or gain approval through a special approval process designed to protect the privacy of your PHI. In some circumstances, we may use your PHI to generate aggregate data (summarized data that does not identify you) to study outcomes, costs and provider profiles, and to suggest benefit designs for your employer or health plan. These studies generate aggregate data that we may sell or disclose to other companies or organizations. Aggregate data does not personally identify you.
• Abuse, Neglect or Domestic Violence: We may disclose your PHI to a social service, protective agency or other government authority if we believe you are a victim of abuse, neglect or domestic violence. We will inform you of our disclosure unless informing you will place you at risk of serious harm.
• Public Health: We may disclose your PHI for public health activities and purposes, such as reporting adverse events, post marketing surveillance in connection with FDA-regulated entities’ legal obligations (e.g., pharmaceutical manufacturer reporting or connections with an FDA-mandated Risk Evaluation and Mitigation Strategies (REMS) program) and product recalls. We may also disclose your PHI to a person or company that is regulated by the U.S. Food and Drug Administration, such as a pharmaceutical manufacturer, for the purpose of: 1. reporting or tracking product defects or problems; 2. repairing, replacing, or recalling defective or dangerous products; or 3. monitoring the performance of a product after it has been approved for use by the general public. We may receive payment from a third party for making disclosures for public health activities and purposes.
• Health Oversight: We may disclose PHI to a health oversight agency performing activities authorized by law, such as investigations and audits. These agencies include governmental agencies that oversee the healthcare system, government benefit programs, and organizations subject to government regulation and civil rights laws.
• To Avert Serious Threat to Health or Safety: We may disclose your PHI to prevent or lessen an imminent threat to the health or safety of another person or the public. Such disclosure will only be made to someone in a position to prevent or lessen the threat.
• Judicial Proceedings: We may disclose your PHI in the course of any judicial proceeding in response to a court order, subpoena or other lawful process, but only after we have been assured that efforts have been made to notify you of the request.
• Law Enforcement: We may disclose your PHI, as required by law, in response to a subpoena, warrant, summons, or in some circumstances, to report crime.
• Coroners and Medical Examiners: We may disclose your PHI to a coroner or a medical examiner for the purpose of determining cause of death or other duties authorized by law.
• Organ, Eye and Tissue Donation: We may disclose your PHI to organizations involved in organ transplantation to facilitate donation and transplantation.
• Workers’ Compensation: We may disclose your PHI in order to comply with workers’ compensation laws and other similar programs.
• Fund Raising: We may use your PHI to send you fundraising communications, but you have the right to opt out of receiving such communications.
• Specialized Government Functions, Military and Veterans: We may disclose your PHI to authorized federal officials to perform intelligence, counter-intelligence, medical suitability determinations, Presidential protection activities, and other national security activities authorized by law. If you are a member of the U.S. armed forces or of a foreign military, we may disclose your PHI as required by military command authorities or law. If you are an inmate in a correctional institution or under the custody of a law enforcement official, we may disclose your PHI to those parties if disclosure is necessary for: 1. the provision of your healthcare; 2. maintaining the health or safety of yourself or other inmates; or 3. ensuring the safety and security of the correctional institution or its agents.
• Other Uses and Disclosures: Most uses and disclosures of psychotherapy notes (where appropriate), uses and disclosures for marketing purposes and disclosures that constitute a sale of PHI require an authorization. Any of these activities and any other uses and disclosures of your PHI not listed in this Notice will be made only with your authorization unless we are permitted by applicable law to make such other use and disclosure in which case we shall comply with applicable law. You may revoke your authorization, in writing, at any time unless we have taken action in reliance upon it. Written revocation of authorization must be sent to the address listed below.
YOUR RIGHTS WITH RESPECT TO YOUR PHI
You have the following rights regarding PHI we maintain about you:
• Right to Inspect and Copy: Subject to some restrictions, you may inspect and copy PHI that may be used to make decisions about you. If we maintain an electronic health record containing your PHI, you have the right to request that we send a copy of your PHI in an electronic format to you or to a third party that you identify.
• Right to Amend: If you believe PHI about you is incorrect or incomplete, you may ask us to amend the information. You must provide a reason supporting your request to amend.
• Right to an Accounting of Disclosures: You have the right to request an accounting of disclosures of your PHI. This accounting identifies the disclosures we have made of your PHI other than for treatment, payment or healthcare operations. The provision of an accounting of disclosures is subject to certain restrictions.
• Right to Request Restrictions: You have the right to request a restriction or limitation on the PHI we use and disclose about you for treatment, payment or healthcare operations. You may also request your PHI not be disclosed to family members or friends who may be involved in your care or paying for your care. Your request must: 1. be in writing; 2. state the restrictions you are requesting; and 3. state to whom the restriction applies. We are not required to agree to your request. If we do agree, we will comply with your request unless the restricted information is needed to provide you with emergency treatment. We will agree to your request to restrict PHI disclosed to a health plan for payment or healthcare operations (i.e., non-treatment) purposes if the information is about a medication for which you paid us, out-of-pocket, in full.
• Confidential Communications: You may ask that we communicate with you in an alternate way or at an alternate location to protect the confidentiality of your PHI. Your request must state an alternate method or location you would like us to use to communicate your PHI to you.
• Right to be Notified: You have the right to be notified following a breach of unsecured PHI if your PHI is affected.
• Right to a Paper Copy of This Notice: You have the right to request a paper copy of this Notice at any time. Please call toll- free 866-643-3547 for information about how to obtain a copy of this Notice. Even if we have agreed to provide this Notice electronically, you are still entitled to a paper copy. You may obtain a copy of this Notice from our website at www.fidelis- rx.com/HIPAA.html.
• Right to File a Complaint: If you believe we have violated your privacy rights, you may file a written complaint to Fidelis Specialty Pharmacy at the address listed below. You may also file a complaint with the Secretary of the Department of Health and Human Services. You will not be retaliated against for filing a complaint.