top of page

HIPAA NOTICE OF PRIVACY PRACTICES FOR PHARMACIES

Effective Date:     1/2/2006, Updated:  12/1/2022

​

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.

​

Wayland Village Drug, Inc. (Wayland Village Pharmacy) has a firm and long-standing commitment to protecting our customers’ privacy. This Notice describes the privacy protections in place for our pharmacy-related services. Whenever you visit or receive services from our pharmacy, you can expect the privacy of your health information to be protected as described in this Notice. We are required by law to maintain the privacy of your health information, to provide you this detailed Notice of our legal duties and privacy practices relating to your health information, and to abide by the terms of the Notice that currently is in effect. We are also required to notify you if you are affected by a breach of unsecured protected health information (“PHI”). For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html. We will not use or share your information other than as described herein.

  • USES AND DISCLOSURES FOR TREATMENT, PAYMENT AND HEALTH CARE OPERATIONS Uses and disclosures of health information for treatment, payment, and health care operations are permitted by the federal Privacy Rule and authorized by the signature log you sign at the pharmacies. The following lists various ways in which we may use or disclose your PHI for these purposes.
    For Treatment. We will use and disclose your PHI in providing you with Pharmacy services and may disclose information to other providers involved in your care. For example, our Pharmacy associates will use your PHI to dispense prescription medications to you in accordance with your provider’s orders. We may contact your provider to discuss your prescription, possible drug interactions, or other concerns.
    For Payment. We may use and disclose your PHI for our billing and payment purposes or for the billing and payment needs of another health care provider. We may disclose your PHI to your representative, to an insurance or managed care company, Medicare, Medicaid, another third-party payer, or another health care entity. For example, we may contact your health plan to confirm your coverage for certain prescription medications or the amount of your co-payment.
    For Health Care Operations. We may use and disclose your PHI as necessary for our health care operations, such as management, personnel evaluation, education, and training. For example, we may use and disclose your PHI to review and improve the quality of our services.
    Prescription Reminders. We may use or disclose PHI to provide “refill reminders” to remind you that your prescriptions are ready to be picked up at the Pharmacy or that it is time for you to refill your prescription.
    Treatment Alternatives and Health-Related Benefits and Services. We may use or disclose your PHI to inform you about treatment alternatives and health-related benefits and services that may be of interest to you. We will not sell lists of pharmacy customers or other PHI to third parties for marketing purposes.

  • SPECIFIC USES AND DISCLOSURES OF YOUR HEALTH INFORMATION The following lists various ways in which we may use or disclose your PHI.
    To the Patient or their Personal Representative for their own use. On request, we will disclose your PHI to you or your Personal Representative (a person who is authorized by law to act on your behalf with respect to health care matters).
    Individuals Involved in Your Care or Payment for Your Care. Unless you provide us with a written objection, we may disclose PHI about you to a family member, close personal friend or a caregiver who is involved in your care or payment for your care, or we may disclose PHI to notify a family member, close personal friend or a caregiver about your general condition or location. Unless a family member has legal authority to act on your behalf, we will only disclose information relevant to that family member’s involvement in your care or payment for your care.
    As Required by Law. We may use or disclose your PHI when required by law to do so.
    Health Oversight Activities. We may disclose your PHI to a health oversight agency, such as the Board of Pharmacy, for activities authorized or required by law, such as audits, investigations and inspections or for activities involving government oversight of the health care system.
    Business Associates. We may disclose your protected health information to a contractor or service provider (known as a “business associate”) that needs the information to perform services for the Pharmacy and that agrees to protect the confidentiality of this information.

  • PERMITTED DISCLOSURES OF YOUR HEALTH INFORMATION In addition to the disclosures described above, we may make the following disclosures, subject to conditions and limits in federal and state law. Note: in some circumstances disclosures listed below may be required by law, and so are also covered in Section II above.Public Health Activities. We may disclose your PHI to a public health authority charged with, for example, preventing or controlling disease, injury or disability.
    Reporting Victims of Abuse, Neglect or Domestic Violence. If we believe that you have been a victim of abuse, neglect or domestic violence, we may use and disclose your PHI to notify a government authority, if authorized or required by law.
    To Avert a Serious Threat to Health or Safety. When necessary to prevent a serious threat to your health or safety or the health or safety of the public or another person, we may use or disclose PHI, limiting disclosures to someone able to help lessen or prevent the threatened harm. For example, we may disclose PHI to help with product recalls or report adverse reactions to medications.
    To Conduct Research. Under certain circumstances, we can use or share your information for research purposes, as long as the procedures required by law to protect the privacy of the research data are followed.
    Judicial and Administrative Proceedings. We may disclose your PHI in response to a court or administrative order. We may also disclose your PHI in response to a subpoena, discovery request, or other lawful process if we receive evidence that the party requesting the information has made reasonable efforts either (i) to notify you of the request, so you have a chance to object, or (ii) to secure a qualified protective order.
    Law Enforcement. We may disclose your PHI for certain law enforcement purposes, including, for example, to comply with reporting requirements; to comply with a court order, warrant, or similar legal process; or to answer certain requests for information concerning crimes.
    Coroners, Medical Examiners, Funeral Directors, Organ Procurement Organizations. In the event of your death, we may release your PHI to a coroner, medical examiner, and funeral director or, if you are an organ donor, to an organization involved in the donation of organs and tissue.
    Disaster Relief. We may disclose limited PHI about you to a disaster relief organization.
    Military, Veterans and other Specific Government Functions. If you are a member of the armed forces, we may use and disclose your PHI as required by military command authorities. We may disclose PHI for national security purposes or as needed to protect the President of the United States or certain other officials or to conduct certain special investigations.
    Workers’ Compensation. We may use or disclose your PHI to comply with laws relating to workers’ compensation or similar programs.
    Inmates/Law Enforcement Custody. If you are under the custody of a law enforcement official or a correctional institution, we may disclose your PHI to the institution or official for certain purposes including the health and safety of you and others.
    If an employee or business associate believes in good faith that we have engaged in conduct that is unlawful or otherwise violates professional or clinical standards, he or she might disclose your PHI to an attorney or a public health authority when sharing his or her concerns with that attorney or public health authority.
    HIPAA Compliance and Enforcement. We may disclose your PHI to the Secretary of HHS for HIPAA rules compliance and enforcement purposes.

  • USES AND DISCLOSURES WITH YOUR AUTHORIZATION Except as described in this Notice, Wayland Village Pharmacy does not intend to use or disclose your PHI. Where there is intention to use or disclose PHI for other purposes, your authorization would be required for certain uses or disclosures, and you could revoke such an authorization in writing at any time. No such authorization is included in your execution of an acknowledgement of this Notice. We will never share your information for marketing purposes or sell your information, unless you give us written permission to do so. Once health information about you has been disclosed pursuant to your authorization, HIPAA protections may no longer apply to the disclosed health information, and that information may be re-disclosed by the recipient without your or our knowledge or authorization.

  • YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION Listed below are your rights regarding your PHI. Each of these rights is subject to certain requirements, limitations and exceptions. Exercise of these rights may require submitting a written request to the Pharmacy. At your request, the Pharmacy will supply you with the appropriate form to complete. You have the right to:
    Request Restrictions. You have the right to request restrictions on our use or disclosure of your PHI for treatment, payment, or health care operations. You also have the right to request restrictions on the PHI we disclose about you to a family member, friend or other person who is involved in your care or the payment for your care. Your request must be made in writing. We will notify you in writing as to whether we agree to your request. We are not required to agree to your requested restriction (except that if you are mentally competent, you may restrict disclosures to family members or friends). If we do agree to accept your requested restriction, we will comply with your request except as needed to provide you emergency treatment or in accordance with federal and state law. However, if you paid out-of-pocket in full for a prescription and do not want us to disclose to your health plan PHI pertaining to that prescription for purposes of payment or health care operations, we must comply with your request.
    Access to Personal Health Information. You have the right to inspect and obtain a copy of your PHI that may be used to make decisions about you – a “designated record set” – for as long as we maintain the PHI. The designated record set usually will include prescriptions and billing records, or other written information that may be used to make decisions about your care, subject to some exceptions. Your request must be made in writing. We generally are required to provide you with access to your health record within thirty (30) days after receipt of your request. To inspect or copy your PHI, you must send a written request to the HIPAA Privacy Representative at the address noted below and complete the appropriate authorization form. In most cases we may charge a reasonable fee to cover our costs in copying and mailing your requested information, consistent with applicable law. To the extent you request records not maintained by us, we will inform you in writing, if known, who maintains the records. We may deny, in writing, your request to inspect or receive copies in certain limited circumstances. If you are denied access to PHI, you may request that the denial decision be reviewed by sending a written request to the HIPAA Privacy Representative at the address noted below. This review would be performed by a licensed health care professional who did not participate in the decision to deny. To the extent we maintain an electronic health record with respect to your PHI, you also have the right to receive such electronic PHI in the electronic form and format you request if it is readily producible or, if not, in a readable electronic form and format mutually agreed upon, and to direct us to transmit an electronic copy directly to a third party designated by you.
    We may charge you a reasonable fee, consistent with applicable law, for the costs of copying, transmitting and/or mailing your PHI in responding to your request.
    Note: Requests at the Pharmacy for copies of your prescription records, such as for tax submission purposes, are not treated as formal Requests for Access and are handled directly by the Pharmacy. If you wish to exercise your right to access your PHI, you should ask the pharmacist for a special “HIPAA Request for Access” form.
    Request Amendment. You have the right to request amendment of your PHI maintained by the Pharmacy for as long as the information is kept by or for the Pharmacy. Your request must be made in writing and must state the reason for the requested amendment. We may deny your request for amendment if the information (a) was not created by the Pharmacy, unless the originator of the information is no longer available to act on your request; (b) is not part of the PHI maintained by or for the Pharmacy; (c) is not part of the information to which you have a right of access; or (d) is already accurate and complete, as determined by the Pharmacy. Form 101/102 If we deny your request for amendment, we will give you a written denial including the reasons for the denial and the right to submit a written statement disagreeing with the denial.
    Note: Simple requests at the Pharmacy, such as changing your address or insurance information, are not treated as formal Requests for Amendment and are handled directly by the Pharmacy. If you wish to exercise your right to request amendments to your PHI, you should ask the pharmacist for a special “HIPAA Request for Amendment” form.
    Request an Accounting of Disclosures. You have the right to request an “accounting” of certain disclosures of your PHI. This is a listing of disclosures made by the Pharmacy or by others on our behalf, but does not include disclosures for treatment, payment and health care operations, disclosure made pursuant to your Authorization, and certain other exceptions. To request an accounting of disclosures, you should ask the pharmacist for a special “HIPAA Request for Accounting” form, stating a time period that is within six years from the date of your request and listing the location of all pharmacies for which you are requesting an accounting. The first accounting provided within a twelve-month period will be free; for further requests, we may charge you our costs.
    Request Confidential Communications by Alternative Means. You have the right to request that we communicate with you concerning your health matters in a certain manner. We will accommodate your reasonable requests.
    Note: Simple requests at the Pharmacy, such as calling a patient at an alternate location when a prescription is ready, are not treated as formal Requests for Confidential Communications and are handled directly by the Pharmacy. If you wish to exercise your right to request confidential communications by alternative means, you should ask the pharmacist for a special “HIPAA Request for Confidential Communications” form.
    Request Someone to Act for You. If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. We will make sure the person has this authority and can act for you before we take any action.
    Request a Paper Copy of This Notice. You have the right to obtain a paper copy of this Notice, even if you have agreed to receive this Notice electronically. You may request a copy of this Notice at any time.

  • FOR FURTHER INFORMATION OR TO FILE A COMPLAINT If you have any questions about this Notice or would like further information concerning your HIPAA privacy rights, please contact the HIPAA Privacy Officer at (269) 792-6223, 300 Reno Drive, Wayland, MI 49348 or waylandvillagerx@gmail.com If you believe that your privacy rights have been violated, you may file a complaint in writing with the Pharmacy or with the Office for Civil Rights in the U.S. Department of Health and Human Services. We will not retaliate against you if you file a complaint. To file a complaint with the Pharmacy, you may request a HIPAA Complaint Form at this pharmacy, or contact the HIPAA Privacy Officer listed above. To file a complaint with the Office for Civil Rights, send your written complaint by mail to Office for Civil Rights, U.S. Department of Health and Human Services, 200 Independence Avenue, S.W., Washington, D.C. 20201 or by email to OCRComplaint@hhs.gov or electronically at https://ocrportal.hhs.gov/ocr/cp/complaint_frontpage.jsf.

  • CHANGES TO THIS NOTICE We reserve the right to change this Notice and to make the revised or new Notice provisions effective for all PHI already received and maintained by the Pharmacy as well as for all PHI we receive in the future. We will post a copy of the revised Notice at our website, www.waylandrx.com, and post a copy of the revised Notice at the pharmacy.

  • MORE STRINGENT STATE LAW If your state has a law or regulation that is more stringent than the HIPAA Privacy Rule, we are required to follow it. If you would like additional information about state law protections in your state, please contact the HIPAA Privacy Officer at (269) 792-6223, 300 Reno Drive, Wayland, MI 49348 or waylandvillagerx@gmail.com.

 

​

Acknowledgment of Receipt of Notice of Privacy Practices

             If you did not provide your signature acknowledging receipt of this Notice at the pharmacy, please complete the section

below, tear off this portion and return it to the pharmacy from which you obtained your prescription:

             By signing below, I acknowledge that I have received a copy of Wayland Village Pharmacy’s Notice of Privacy Practices:

 

___________________________________    ________________________________     ____________

Name of Customer                                                          Signature                                                             Date

 

WAYLAND VILLAGE PHARMACY  300 Reno Dr.  Wayland, MI 49348        __________________________

Pharmacy Name / Address                                                                                          Prescription Number

 

If signed by the patient’s Personal Representative, please print your name and describe your relationship to the customer or other authority to act.

 

_______________________________________          _______________________________________

Print Name                                                                                        Relationship to Patient

bottom of page