Apthorp, Your Neighborhood Pharmacy
Introduction
Apthorp Pharmacy understands that your medical information is private and confi dential. Further, we are required by law to maintain the privacy of “protected health information.” “Protected health information” includes any individually identifi able information that we obtain from you or others that relates to your past, present or future physical or mental health, the health care you have received, or payment for your health care. As required by law, this notice provides you with information about your rights and our legal duties and privacy practices with respect to the privacy of protected health information. This notice also discusses the uses and disclosures we will make of your protected health information. We must comply with the provisions of this notice as currently in effect, although we reserve the right to change the terms of this notice from time to time and to make the revised notice effective for all protected health information we maintain. You can always request a written copy of our most current privacy notice from the Pharmacy’s Privacy Offi cer. If you have any questions or would like further information about this notice, please contact the Pharmacy’s Privacy Offi cer.

Permitted Uses and Disclosures
We can use or disclose your protected health information for purposes of treatment, payment and health care operations. For each of these categories of uses and disclosures, we have provided a description and an example below. However, not every particular use or disclosure in every category will be listed.

Your Rights
1. You have the right to request restrictions on our uses and disclosures of protected health information for treatment, payment and health care operations. However, we are not required to agree to your request. To request a restriction, you must make your request in writing to the Pharmacy’s Privacy Offi cer.

2. You have the right to reasonably request to receive confi dential communications of protected health information by alternative means or at alternative locations. To make such a request, you must submit your request in writing to the Pharmacy’s Privacy Offi cer.

3. Subject to certain limited exceptions, you have the right to inspect and copy the protected health information contained in your medical and billing records and in any other Pharmacy records used by us to make decisions about you. In order to inspect and copy your health information, you must submit your request in writing to the Pharmacy’s Privacy Offi cer. If you request a copy of your health information, we may charge you a fee for the costs of copying and mailing your records, as well as other costs associated with your request.

4. You have the right to request an amendment to your protected health information, but we may deny your request for amendment in certain limited situations. In any event, any agreed upon amendment will be included as an addition to, and not a replacement of, already existing records. In order to request an amendment to your health information, you must submit your request in writing to the Pharmacy’s Privacy Offi cer, along with a description of the reason for your request.

5. You have the right to receive an accounting of certain disclosures of protected health information made by us to individuals or entities other than to you for the six years prior to your request, except for disclosures for which we are not required to keep an accounting, such as disclosures for treatment, payment and health care operations. To request an accounting of disclosures of your health information, you must submit your request in writing to the Pharmacy’s Privacy Offi cer. Your request must state a specifi c time period for the accounting (e.g., the past three months). The fi rst accounting you request within a twelve (12) month period will be free. For additional accountings, we may charge you for the costs of providing the list. We will notify you of the costs involved, and you may choose to withdraw or modify your request at that time before any costs are incurred.

Complaints
If you believe that your privacy rights have been violated, you should immediately contact the Pharmacy’s Privacy Offi cer. We will not take action against you for fi ling a complaint. You also may fi le a complaint with the Secretary of Health and Human Services.

Apthorp Pharmacy
2201 Broadway (at 78th Street)
New York, NY 10024
Tel: (212) 877-3480 Fax: (212) 769-9095


Privacy Notice
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 Privacy Notice is effective as of April 14, 2003.

Other Uses and Disclosures of Protected Health Information
In addition to using and disclosing your information for treatment, payment and health care operations, we may use your protected health information in the following ways: Special Situations
Subject to the requirements of applicable law, we will make the following uses and disclosures of your protected health information: Note: Information regarding HIV, genetics, alcohol and/or substance abuse, mental health and other specially protected health information may enjoy certain special confi dentiality protections under applicable State and Federal law. Any disclosures of these types of records will be subject to these special protections.

Other Uses of Your Health Information
Other uses and disclosures of protected health information not covered by this notice or the laws that apply to us will be made only with your permission in a written authorization. You have the right to revoke that authorization at any time, provided that the revocation is in writing, except to the extent that we already have taken action in reliance on your authorization.

 


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