GLENRIDGE PHARMACY LLC
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.
As part of the federal Health Insurance Portability and Accountability Act of 1996, known as HIPAA, the Pharmacy
has created this Notice of Privacy Practices (Notice). This Notice describes the Pharmacy’s privacy practices and the
rights you, the individual, have as they relate to the privacy of your Protected Health Information (PHI). Your PHI is
information about you, or that could be used to identify you, as it relates to your past and present physical and mental
health care services. The HIPAA regulations require that the Pharmacy protect the privacy of your PHI that the
Pharmacy has received or created.
This Pharmacy will abide by the terms presented within this Notice. For any uses or disclosures that are not listed
below (Including Marketing and Selling of PHI), the Pharmacy will obtain a written authorization from you for that use
or disclosure, which you will have the right to revoke at any time, as explained in more detail below.
The Pharmacy reserves the right to change the Pharmacy’s privacy practices and this Notice.
HOW THE PHARMACY MAY USE AND DISCLOSE YOUR PHI
The following is an accounting of the ways that the Pharmacy is permitted, by law, to use and disclose your PHI.
Uses and disclosures of PHI for Treatment:
We will use the PHI that we receive from you to fill your prescription and coordinate or manage your health care.
Uses and disclosures of PHI for Payment: The Pharmacy will disclose your PHI to obtain payment or reimbursement
from insurers for your health care services.
Uses and disclosures of PHI for Health Care Operations: The Pharmacy may use the minimum necessary amount
of your PHI to conduct quality assessments, improvement activities, and evaluate the Pharmacy workforce.
The following is an accounting of additional ways in which the Pharmacy is permitted or required
to use or disclose PHI about you without your written authorization.
Uses and disclosures as required by law: The Pharmacy is required to use or disclose PHI about you as required
and as limited by law.
Uses and disclosure for Public Health Activities: The Pharmacy may use or disclose PHI about you to a public health
authority that is authorized by law to collect for the purpose of preventing or controlling disease, injury, or disability.
This includes the FDA so that it may monitor any adverse effects of drugs, foods, nutritional supplements and other
products as required by law.
Uses and disclosure about victims of abuse, neglect or domestic violence: The Pharmacy may use or disclose
PHI about you to a government authority if it is reasonably believed you are a victim of abuse, neglect or domestic
Uses and disclosures for health oversight activities: The Pharmacy may use or disclose PHI about you to a health
oversight agency for oversight activities which may include audits, investigations, inspections as necessary for licensure,
compliance with civil laws, or other activities the health oversight agency is authorized by law to conduct.
Disclosures to Individuals Involved in your Care: The Pharmacy may disclose PHI about you to individuals involved
in your care.
Disclosures for judicial and administrative proceedings: The Pharmacy may disclose PHI about you in the course of
any judicial or administrative proceedings, provided that proper documentation is presented to the Pharmacy.
Disclosures for law enforcement purposes: The Pharmacy may disclose PHI about you to law enforcement
officials for authorized purposes as required by law or in response to a court order or subpoena.
Uses and disclosures about the deceased: The Pharmacy may disclose PHI about an a deceased, or prior to,
and in reasonable anticipation of individual’s death, to coroners, medical examiners, and funeral directors.
Uses and disclosures for cadaveric organ, eye or tissue donation purposes: The Pharmacy may use and
disclose PHI for the purpose of procurement, banking, or transplantation of cadaveric organs, eyes, or tissues for donation
Uses and disclosures for research purposes: The Pharmacy may use and disclose PHI about you for research
purposes with a valid waiver of authorization approved by an institutional review board or a privacy board. Otherwise,
the Pharmacy will request a signed authorization by the individual for all other research purposes.
Uses and disclosures to avert a serious threat to health or safety: The Pharmacy may use or disclose PHI about
you, if it believed in good faith, and is consistent with any applicable law and standards of ethical conduct, to avert
a serious threat to health or safety.
Uses and disclosures for specialized government functions: The Pharmacy may use or disclose PHI about you
for specialized government functions including; military and veteran’s activities, national security and intelligence,
protective services, department of state functions, and correctional institutions and law enforcement custodial
Disclosure for workers’ compensation: The Pharmacy may disclose PHI about you as authorized by and to the
extent necessary to comply with workers’ compensation laws or programs established by law.
Disclosures for disaster relief purposes: The Pharmacy may disclose PHI about as authorized by law to a public
or private entity to assist in disaster relief efforts and for family and personal representative notification.
Disclosures to business associates: The Pharmacy may disclose PHI about you to the Pharmacy’s business
associates for services that they may provide to or for the Pharmacy to assist the Pharmacy to provide quality health care.
To ensure the privacy of your PHI, we require all business associates to apply appropriate safeguards to any PHI
they receive or create.
OTHER USES AND DISCLOSURES
The Pharmacy may contact you for the following purposes:
Information about treatment alternatives: The Pharmacy may contact you to notify you of alternative treatments
Health related benefits or services: The Pharmacy may use your PHI to notify you of benefits and services the
Fundraising: If the Pharmacy participates in a fundraising activity, the Pharmacy may use demographic PHI to send you
a fundraising packet, or the Pharmacy may disclose demographic PHI about you to its business associate or an
institutionally related foundation to send you a fundraising packet. No further disclosure will be allowed by the
business associates or an institutionally related foundation without your written authorization. You will be provided with
an opportunity to opt‐out of all future fundraising activities.
FOR ALL OTHER USES AND DISCLOSURES
The Pharmacy will obtain a written authorization from you for all other uses and disclosures of PHI, and the Pharmacy
will only use or disclose pursuant to such an authorization. In addition, you may revoke such an authorization in writing
at any time. To revoke a previously authorized use or disclosure, please contact [PRIVACY OFFICER], to obtain a
Request for Restriction of Uses and Disclosures
YOUR HEALTH INFORMATION RIGHTS
The following are a list of your rights in respect to your PHI. Please contact [the PRIVACY OFFICER], for more
information about the below.
Request restrictions on certain uses and disclosures of your PHI: You have the right to request additional
Pharmacy’s uses and disclosures of your PHI; however, the Pharmacy is not required to accommodate a request.
This includes the right to restrict disclosures to Insurances for those products and services you pay out‐of‐pocket
The right to have your PHI communicated to you by alternate means or locations:
You have the right to request that the Pharmacy communicate confidentially with you using an address or phone
number other than your residence. However, state and federal laws require the Pharmacy to have an accurate
address and home phone number in case of emergencies. The Pharmacy will consider all reasonable requests.
The right to inspect and/or obtain a copy your PHI: You have the right to request access and/or obtain a copy of
your PHI that is contained in the Pharmacy for the duration the Pharmacy maintains PHI about you. There may be a
reasonable cost‐based charge for photocopying documents. You will be notified in advance of incurring such charges,
The right to amend your PHI: You have the right to request an amendment of the PHI the Pharmacy
maintains about you, if you feel that the PHI the Pharmacy has maintained about you is incorrect or otherwise
incomplete. Under certain circumstances we may deny your request for amendment. If we do deny the request,
you will have the right to have the denial reviewed by someone we designate who was not involved in the initial review.
You may also ask the Secretary, United States Department of Health and Human Services (“HHS”), or their appropriate
designee, to review such a denial.
The right to receive an accounting of disclosures of your PHI: You have the right to receive an accounting of
certain disclosures of your PHI made by the Pharmacy.
The right to receive additional copies of the Pharmacy’s Notice of Privacy Practices:
You have the right to receive additional paper copies of this Notice, upon request, even if you initially agreed to
receive the Notice electronically
Notification of Breaches: You will be notified of any breaches that have compromised the privacy of your PHI.
REVISIONS TO THE NOTICE OF PRIVACY PRACTICES
The Pharmacy reserves the right to change and/or revise this Notice and make the new revised version applicable to all
PHI received prior to its effective date. The Pharmacy will also post the revised version of the Notice in the Pharmacy.
If you believe your privacy rights have been violated, you may file a complaint with the Pharmacy and/or to the
Secretary of HHS, or his designee. If you wish to file a complaint with the Pharmacy, please contact [PRIVACY
OFFICER]. If you wish to file a complaint with the Secretary, please write to
The Pharmacy will not take any adverse action against you as a result of your filing of a complaint.
If you have any questions on the Pharmacy’s privacy practices or for clarification on anything contained within
the Notice, please contact:
GLENRIDGE PHARMACY LLC
68-01 MYRTLE AVE
GLENDALE, NY 11385