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.
Sip Pharmacy LLC dba Sip Pharmacy and Wellness (hereinafter Sip Pharmacy) uses health information about you for treatment, to obtain payment for treatment, to evaluate the quality of care you receive, and for other administrative and operational purposes. Your health information is contained in a medical record that is the physical property and responsibility of Sip Pharmacy. Sip Pharmacy is required by law to maintain the privacy of health information about you and provide you with this notice of our legal duties and privacy practices with respect to your health information ("Notice of Privacy Practices" or "Notice"). We must abide by the terms of this Notice currently in effect. Sip Pharmacy reserves the right to change the terms of this Notice, our privacy practices, and to make the new provisions effective for all protected health information we maintain. You may contact Sip Pharmacy or Sip Pharmacy's Chief Privacy Officer at the address or phone number listed below to obtain a revised Notice of Privacy Practices.
Protected Health Information ("PHI") means individually identifiable health information, as defined by HIPAA, that is created or received by us and that relates to the past, present, or future physical or mental health or condition of an individual; the provision of health care to an individual; or the past, present, or future payment for the provision of health care to an individual; and that identifies the individual or for which there is a reasonable basis to believe the information can be used to identify the individual. PHI includes information of persons living or deceased.
USES AND DISCLOSURES OF YOUR PROTECTED HEALTH INFORMATION
The following categories describe different ways that we use and disclose PHI. For each category of uses and disclosures we will explain what we mean and, where appropriate, provide examples for illustrative purposes. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted or required to use and disclose PHI will fall within one of the categories.
Your Authorization - Except as outlined below, we will not use or disclose your PHI unless you have signed a form authorizing the use or disclosure. You have the right to revoke that authorization in writing except to the extent that we have taken action in reliance upon the authorization or that the authorization was obtained as a condition of obtaining coverage under the group health plan, and we have the right, under other law, to contest a claim under the coverage or the coverage itself.
Uses and Disclosures for Treatment - We may use and disclose health information about you to provide you with pharmacy care or other medical treatment or services. For example, information related to your treatment may be communicated with and obtained by a health care provider, such as a pharmacist, nurse, or other person providing health services to you, and will be recorded in your medical record. This information is necessary for health care providers to determine what treatment you should receive.
Uses and Disclosures for Payment - We may make requests, uses, and disclosures of your PHI as necessary for payment purposes. For example, we may use information regarding your medical procedures and treatment to process and pay claims. We may also disclose your PHI for the payment purposes of a health care provider or a health plan.
Uses and Disclosures for Health Care Operations - We may use and disclose health information about you for administrative and operational purposes. For example, members of the risk management or quality improvement teams may use health information about you to assess the care and outcomes in your case and others like it. The results will be used internally to continually improve the quality of care for all patients.
Family and Friends Involved in Your Care - If you are available and do not object, we may disclose your PHI to your family, friends, and others who are involved in your care or payment of a claim. If you are unavailable or incapacitated and we determine that a limited disclosure is in your best interest, we may share limited PHI with such individuals. For example, we may use our professional judgment to disclose PHI to your spouse concerning the processing of a claim.
Business Associates - We provide some services through contracts with business associates, such as accountants, consultants, and attorneys so that they can perform the tasks that we have assigned to them. To protect your health information, we require the business associate to appropriately safeguard health information about you.
Other Uses and Disclosures - We may make certain other uses and disclosures of your PHI without your authorization:
We may use or disclose your PHI for any purpose required by law. For example, we may be required by law to use or disclose your PHI to respond to a court order.
We may disclose your PHI for public health activities, such as reporting of disease, injury, birth and death, and for public health investigations.
We may disclose your PHI to the proper authorities if we suspect child abuse or neglect; we may also disclose your PHI if we believe you to be a victim of abuse, neglect, or domestic violence.
We may disclose your PHI if authorized by law to a government oversight agency (e.g., a state insurance department) conducting audits, investigations, or civil or criminal proceedings.
We may disclose your PHI in the course of a judicial or administrative proceeding (e.g., to respond to a subpoena or discovery request).
We may disclose your PHI to the proper authorities for law enforcement purposes.
We may disclose your PHI to coroners, medical examiners, and/or funeral directors consistent with law.
We may use or disclose your PHI for cadaveric organ, eye or tissue donation.
We may use or disclose your PHI for research purposes, but only as permitted by law.
We may use or disclose PHI to avert a serious threat to health or safety.
We may use or disclose your PHI if you are a member of the military as required by armed forces services, and we may also disclose your PHI for other specialized government functions such as national security or intelligence activities.
We may disclose your PHI to workers' compensation agencies for your workers' compensation benefit determination.
We will, if required by law, release your PHI to the Secretary of the Department of Health and Human Services for enforcement of HIPAA.
In the event that applicable law, other than HIPAA, prohibits or materially limits our uses and disclosures of Protected Health Information, as described above, we will restrict our uses or disclosure of your Protected Health Information in accordance with the more stringent standard.
RIGHTS THAT YOU HAVE
Access to Your PHI - You have the right of access to copy and/or inspect your PHI that we maintain in designated record sets. Certain requests for access to your PHI must be in writing, must state that you want access to your PHI and must be signed by you or your representative (e.g., requests for medical records provided to us directly from your health care provider). Access request forms are available from Sip Pharmacy at the address below. We may charge you a fee for copying and postage.
Amendments to Your PHI - You have the right to request that PHI that we maintain about you be amended or corrected. We are not obligated to make all requested amendments but will give each request careful consideration. To be considered, your amendment request must be in writing, must be signed by you or your representative, and must state the reasons for the amendment/correction request. Amendment request forms are available from us at the address below.
Accounting for Disclosures of Your PHI - You have the right to receive an accounting of certain disclosures made by us of your PHI. Examples of disclosures that we are required to account for include those to state insurance departments, pursuant to valid legal process, or for law enforcement purposes.
To be considered, your accounting requests must be in writing and signed by you or your representative. Accounting request forms are available from us at the address below. The first accounting in any 12-month period is free; however, we may charge you a fee for each subsequent accounting you request within the same 12-month period.
Restrictions on Use and Disclosure of Your PHI - You have the right to request restrictions on certain of our uses and disclosures of your PHI for insurance payment or health care operations, disclosures made to persons involved in your care, and disclosures for disaster relief purposes. For example, you may request that we not disclose your PHI to your spouse. Your request must describe in detail the restriction you are requesting.
We are not required to agree to your request but will attempt to accommodate reasonable requests when appropriate. We retain the right to terminate an agreed-to restriction if we believe such termination is appropriate. In the event of a termination by us, we will notify you of such termination. You also have the right to terminate, in writing or orally, any agreed-to restriction. You may make a request for a restriction (or termination of an existing restriction) by contacting us at the telephone number or address below.
Request for Confidential Communications - You have the right to request that communications regarding your PHI be made by alternative means or at alternative locations. For example, you may request that messages not be left on voice mail or sent to a particular address. We are required to accommodate reasonable requests if you inform us that disclosure of all or part of your information could place you in danger. Requests for confidential communications must be in writing, signed by you or your representative, and sent to us at the address below.
Right to a Copy of the Notice - You have the right to a paper copy of this Notice upon request by contacting us at the telephone number or address below.
Complaints - If you believe your privacy rights have been violated, you can file a complaint with us in writing at the address below. You may also file a complaint in writing with the Secretary of the U.S. Department of Health and Human Services in Washington, D.C., within 180 days of a violation of your rights. There will be no retaliation for filing a complaint.
FOR FURTHER INFORMATION
If you have questions or need further assistance regarding this Notice, you may contact Sip Pharmacy's Office at 201-222-5452 or Sip Pharmacy’s Privacy Office by writing to: Nikki Baniewicz, Attn: General Counsel, 722 Courtyard Drive, Hillsborough, NJ 08844 or by calling 973-869-2820.
EFFECTIVE DATE: June 1, 2019.