Old Port Pharmacy,
Effective Date: October 1, 2006
THIS NOTICE DESCRIBES HOW INFORMATION ABOUT YOU MAY BE USED
AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT
Who Follows This Notice?
- All Old Port Pharmacy employees,
staff, and business associates.
Our Pledge Regarding information:
We understand that information about you and your health is personal. We are committed to protecting information about you.
We create a record of the care and services you receive. We need this
record to provide you with quality care and to comply with certain legal requirements.
This notice will tell you about the ways in which we may use and disclose information
about you. We also describe your rights and certain obligations we have regarding
the use and disclosure of information.
We are required by law to:
- Make sure the information
that identifies you is kept private.
- Give you this notice of our
legal duties and privacy practices with respect to information about you.
- Follow the terms of the notice
that is currently in effect.
How We May Use and Disclose information About You
The following categories describe different ways that we use and disclose information. For each category of uses or disclosures we will explain what we mean and try to give
some examples. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information will fall
within one of the categories.
- Individuals Involved in
your Care or Payment for Your Care. We report or release information about
you as authorized on the Release of Information Form that is signed by you at the time of Prescription pick-up . For example a friend or family member who is involved in your medical care may receive information if they
are designated by you to do so.
- As Required By Law. We will disclose information about you when required to do so by federal, state or
local law. For example, if there is a federal government audit of prescription
insurance claims, we would release the required information.
- Public Health Risks. We may disclose information about you for public health activities. These activities generally include notifying the appropriate government authority if we believe a patient
has been the victim of abuse, neglect or domestic violence. We will only make
this disclosure if you agree or when we are required or authorized to do so by law.
- Health Oversight Activities. We may disclose information to a health oversight agency for activities authorized
by law. These oversight activities include, for example, 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.
- Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, we may disclose information about you
in response to a court or administrative order. We may also disclose information
about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but
only if reasonable efforts have been made to tell you about the request or to obtain an order protecting the information requested.
- Law Enforcement. We may release information if asked to
do so by a law enforcement official:
- In response to a court order,
subpoena, warrant, summons or similar process.
- To identify or locate a suspect,
fugitive, material witness, or missing person.
- About the victim of a crime
if, under certain limited circumstances, we are unable to obtain the person’s agreement.
- About a death we believe
may be the result of criminal conduct.
- About criminal conduct in
- In emergency circumstances
to report a crime; the location of the crime or victims; or the identity, description or location of the person who committed
- National Security and Intelligence
Activities. We may release 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. We may disclose 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
- Inmates. If you are an inmate of a correctional institution or under the custody of a law enforcement official,
we may release information about you to the correctional institution or law enforcement official. This release would be necessary (1) for the institution to provide you with health care; (2) to protect
your health and safety or the health and safety of others; or (3) for the safety and security of the correctional institution.
Your Rights Regarding information About You
You have the following rights regarding information we maintain about you:
- Right to Inspect and Copy. You have the right to inspect and request a copy of information that may be used to
make decisions about your care.
To inspect and request a copy information that may be used to make decisions
about you, you may ask the pharmacist on duty, or submit your request in writing to the OLD PORT PHARMACY Privacy Manager
(195 Middle St., Portland,
Maine 04101 or email@example.com). If you request a copy of the information, we may charge a fee for the costs
of copying, mailing or other supplies associated with your request.
We may deny your request to inspect and copy in certain very limited
circumstances. If you are denied access to information, you may request that
the denial be reviewed. Another health care professional chosen by OLD PORT PHARMACY
will review your request and the denial. The person conducting the review will
not be the person who denied your request. We will comply with the outcome of
- Right to Amend. If you feel that information we have about you is incorrect or incomplete, you may
ask us to amend the information. You have the right to request an amendment for
as long as the information is kept by or for Old Port Pharmacy.
To request an amendment, you may either ask the pharmacist on duty, or
you may submit your request in writing to the OLD PORT PHARMACY Privacy Manager (195
Middle St., Portland, Maine 04101
or firstname.lastname@example.org). In addition, you must provide a reason that supports your request.
We may deny your request for an amendment if it is not in writing or
does not include a reason to support the request. In addition, we may deny your
request if you ask us to amend information that:
- Was not created by us, unless
the person or entity that created the information is no longer available to make the amendment.
- Is not part of the information
kept by or for OLD PORT PHARMACY .
- Is not part of the information
that you would be permitted to inspect and copy.
- Is accurate and complete.
- Right to an Accounting
of Disclosures. You have the right to request an “accounting of disclosures.” This is a list of the disclosures we made of information about you.
- Right to Request Restrictions. You have the right to request a restriction or limitation on the information we use
or disclose about you for treatment, payment or health care operations. You also
have the right to request a limit on the information we disclose about you to someone who is involved in your care or the
payment for your care, like a family member or friend.
We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you emergency
To request restrictions, you must submit your request in writing to the
OLD PORT PHARMACY Privacy Manager (195 Middle St., Portland,
Maine 04101 or email@example.com). In your request, you must tell us (1) what information your want to limit;
(2) whether you want to limit our use, disclosure or both; and (3) to whom you want the limits to apply.
- Right to Request Confidential Communications.
You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail.
To request confidential communications, you must submit your request
in writing to the OLD PORT PHARMACY Privacy Manager (195 Middle St.,
Portland, Maine 04101
or firstname.lastname@example.org). We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request
must specify how or where you wish to be contacted.
- Right to a Paper Copy of
This Notice. You have the right to a paper copy of this notice. You may ask us to give you 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 this notice.
You may obtain a copy of this notice at our website, www.oldportrx.com.
To obtain a paper of this notice, contact the Old Port Pharmacy Privacy
Manager (195 Middle St., Portland,
ME. 04101 or email@example.com).
Changes to This Notice
We reserve the right to change this notice.
We reserve the right to make the revised or changed notice effective for information we already have about you as well
as any information we receive in the future. We will post a copy of the current
notice on the OLD PORT PHARMACY website and have it on file at OLD PORT PHARMACY. The notice will contain on the first page,
in the top right-hand corner, the effective date.
If you believe your privacy rights have been violated, you may file a complaint
with OLD PORT PHARMACY or with the Secretary of the Department of Health and Human Services.
To file a complaint with OLD PORT PHARMACY, contact the OLD PORT PHARMACY Privacy Manager at 195 Middle St., Portland, ME.
04101, by phone 207-772-2164 or firstname.lastname@example.org. All complaints must be submitted in writing.
You cannot be penalized for filing a complaint.
Other Uses of information
Other uses and disclosures of information not covered by this notice or the
laws that apply to us will be made only with your written permission. If you
provide us permission to use or disclose information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose information about
you for the reasons covered by your written authorization. You understand that
we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our
records of the care that we provided to you.