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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.

Uses and Disclosures: We will use and disclose elements of your protected health information (PHI) in the following ways:

Without your signed authorization:

• Treatment: including, but not limited to, inpatient, outpatient or psychiatric care.
• To your treating physician(s).
• Payment: including, but not limited to, asking you about your health care plan(s), or other sources of payment preparing and sending bills or claims; and collecting unpaid amounts, either ourselves or through a collection agency or attorney.
• Health care operations: including, but not limited to, financial or billing audits; internal quality assurance; personnel decisions;

        participation in managed care plans; defense of legal matters; business planning; and outside storage of our records.

• Disclosures when release is authorized by law: including, but not limited to, judicial settings and to health oversight regulatory agencies, law enforcement and correctional institutions.
• Uses or disclosures for specialized government functions: including, but not limited to, the protection of the         President or high-ranking        government officials; for lawful national intelligence activities; for military purposes; or for the evaluation and health of members of the foreign services.
• In emergency situations or to avert serious health / safety situations.
• If you are a member of the armed forces, we may release medical information about you and your dependents as requested by military command authorities.
• Disclosures of de-identified information.
• Disclosures relating to worker’s compensation claims.
• To medical examiners, coroners or funeral directors to aid in identifying you or to help them in performing their duties.
• To organizations that handle organ and tissue donations.
• To public health organizations or federal organizations in the event of a communicable disease or to report a defective device or untoward event to a biological product (food or medication).
• Disclosures to “business associates” who perform health care operations for us and who commit to respect the privacy of your health information.
• We may include certain limited information about you in the hospital directory while you are a patient at the hospital.
• This information may include your name, location in the hospital, your general condition (e.g., fair, stable, etc.) and your religious affiliation.
• You may be contacted by the hospital to remind you of any appointments, health care treatment alternatives and other health-related benefits and services offered by the hospital.
• You may be contacted by the hospital for the purposes of raising funds to support the hospital’s operations.

Personal Privacy Protection Directive

In accordance with Kalamazoo Long Term Care Pharmacy’s Notice of Privacy Practices and to protect the confidentiality of my protected health information, I hereby direct that disclosure of my protected health information be restricted. Specifically, no documentation of any information related to my stay or treatment, including but not limited to, any documents or other materials prepared for peer review, risk management, or quality assurance purposes, is to be disclosed under any circumstances, redacted or otherwise, to anyone not affiliated with Heritage Community, for any purpose other than payment or legitimate health care operations, without my express written consent or the express written consent of my authorized representative.

Other Uses and Disclosures

Your Rights: You have the following rights concerning your protected health information (PHI):

Restrictions: To request restricted access to all or part of your protected health information (PHI). To do this, contact the HIPAA Privacy and Security Officer. We are not required to grant your request and you do not have the right to restrict disclosures required by law. If we do agree, we must honor the restrictions you request.

Confidential Communications: To receive correspondence of confidential information by alternate means or location such as phoning you at work rather than at home or mailing your health information to a different address. To do this, contact the HIPAA Privacy and Security Officer. We will take reasonable actions to accommodate your request.

Access: To inspect or receive copies of your protected health information (PHI). To do this, contact the HIPAA Privacy and Security Officer. In certain circumstances you may not have the right to access your records if Kalamazoo Long Term Care Pharmacy reasonably believes (or has reason to believe) that such access would cause harm. Examples include, but are not limited to, certain psychotherapy notes, information compiled in reasonable anticipation of or for use in civil, criminal or administrative actions or proceedings, or information obtained from someone other than a healthcare provider under a promise of confidentiality and the access requested would be reasonably likely to reveal the source of the information.

Amendments / Corrections: To request changes be made to your protected health information (PHI). To do this, contact the HIPAA Privacy and Security Officer. We are not required to grant your request if we did not create the record or the record is accurate and complete. If we deny your request for amendment / correction, we will notify you why, how you can attach a statement of disagreement to your records (which we may rebut), and how you can complain. If we agree to the request, we will make the correction within 60 days and will send the corrected information to persons we know who got the wrong information, and others you specify.

Accounting: To receive an accounting of the disclosures by us of your protected health information (PHI) of the six years (or shorter time) prior to your request. To do this, contact the HIPAA Privacy and Security Officer. By law, the list will not include disclosures for purposes of treatment, payment or health care operations; disclosures with your authorization; incidental disclosures; disclosures required by law; and some other limited disclosures. you are entitled to one such list per year without charge. If you want more frequent lists, you will have to pay for them in advance. We will usually respond to your request within 60 days of receiving it, but by law, we can have one 30-day extension of time if we notify you of the extension in writing. We are not required to give you a list of disclosures that occurred before April 14, 2003.

This Notice: To get updates or reissue of this notice, at your request.

Complaints: To complain to us or the U.S. Department of Health & Human Services if you feel your privacy rights have been violated. To register a complaint with us, contact the pharmacy manager. The law forbids us from taking retaliatory action against you if you complain.

Privacy Contact: For more information about our privacy practices, please contact:

James Liang, PharmD

Privacy and Security Officer

Kalamazoo Long Term Care Pharmacy

1000 S. Burdick Street

Kalamazoo, MI 49001

(269) 388-4850