LDI Integrated Pharmacy Services
701 Emerson Road, Suite 301
Creve Coeur, Missouri 63141
NOTICE OF PRIVACY PRACTICES
THIS NOTICES DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY
In accordance with federal law, LDI Pharmacy Benefit Management and Union Plaza Pharmacy (“LDI”) is required to maintain the privacy of Protected Health Information (“PHI”) and to provide you with notice of our legal duties and privacy practices with respect to PHI. PHI is information that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services. This Notice of Privacy Practices (“Notice”) describes how we may use and disclose PHI to carry out treatment, payment or health care operations and for other specified purposes that are permitted or required by law. The Notice also describes your rights with respect to PHI about you.
LDI is required to follow the terms of this Notice. We will not use or disclose PHI about you without your written authorization, except as described in this Notice. We are required to notify affected individuals following a breach of unsecured PHI. We reserve the right to change our practices and this Notice, and to make the new Notice effective for all PHI we maintain. Upon request, we will provide any revised Notice to you.
Your Health Information Rights - You have the following rights with respect to PHI about you:
Obtain a paper copy of the Notice upon request. You have the right to receive a paper copy of the Notice at any time. Even if you have agreed to receive the Notice electronically, you are still entitled to a paper copy. To obtain a paper copy, contact Privacy Officer, LDI Pharmacy Benefit Management 701 Emerson Road, Suite 301, Creve Coeur, MO 63141.
Request a restriction on certain uses and disclosures of PHI. You may request restrictions on certain uses and disclosures of your health information. You have the right to request a limit on our disclosure of PHI about you to someone who is involved in your care or the payment of your care. Although we will consider your request, please be aware that we are under no obligation to accept it or to abide by it unless the request concerns a disclosure of PHI to a health plan for purposes of carrying out payment or health care operations, and the PHI pertains solely to a health care service for which the provider has been paid out of pocket in full. To request such restrictions, contact Privacy Officer, LDI Pharmacy Benefit Management 701 Emerson Road, Suite 301, Creve Coeur, MO 63141
Inspect and obtain a copy of PHI. You have the right to access and copy PHI about you contained in a designated record set for as long as LDI maintains the PHI. The designated record set usually will include prescription and billing records. To inspect or copy PHI about you, you must send a written request to Privacy Officer, LDI Pharmacy Benefit Management 701 Emerson Road, Suite 301, Creve Coeur, MO 63141. We may charge you a fee for the costs of copying, mailing and supplies that are necessary to fulfill your request. If the PHI that is the subject of a request is maintained in one or more designated record sets electronically and if you request an electronic copy of such information, we will provide you with access to the PHI in the electronic form and format requested if readily producible in such form and format; or, if not, in a readable electronic form and format as agreed upon by us and you. We may deny your request to inspect and copy in certain limited circumstances, such as if access is restricted for clear and documented treatment reasons. If you are denied access to PHI about you, you may request that the denial be reviewed.
Request an amendment of PHI. If you feel that PHI we maintain about you is incomplete or incorrect, you may request that we amend it. You may request an amendment for as long as we maintain the PHI. To request an amendment, you must send a written request to Privacy Officer, LDI Pharmacy Benefit Management 701 Emerson Road, Suite 301, Creve Coeur, MO 63141. We may deny the request if it is not in writing, or does not include a reason for the amendment. The request also may be denied if your health information records were not created by us, if the records you are requesting are not part of our records, if the health information you wish to amend is not part of the health information you are permitted to inspect and copy, or if, in our opinion, the records containing your health information are accurate and complete. If we deny your request for amendment, you have the right to file a statement of disagreement with the decision and we may give a rebuttal to your statement.
Receive an accounting of disclosures of PHI. You have the right to receive an accounting of the disclosures we have made of PHI about you after April 14, 2003 for most purposes other than treatment, payment, or health care operations. The accounting will exclude certain disclosures, such as disclosures made directly to you; disclosures you authorize, disclosures to friends or family members involved in your care, and disclosures for notification purposes. The right to receive an accounting is subject to certain other exceptions, restrictions, and limitations. To request an accounting, you must submit a request in writing to Privacy Officer, LDI Pharmacy Benefit Management 701 Emerson Road, Suite 301, Creve Coeur, MO 63141Your request must specify the time period, but may not be longer than six years. The first accounting you request within a 12-month period will be provided free of charge, but you may be charged for the cost of providing additional accountings. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time.
Request communications of PHI by alternative means or at alternative locations. You have the right to request that we communicate with you in a confidential manner. For instance, you may request that we contact you about medical matters only in writing or at a different residence or post office box. To request confidential communication of PHI about you, you must submit a request in writing to Privacy Officer, LDI Pharmacy Benefit Management 701 Emerson Road, Suite 301, Creve Coeur, MO 63141. Your request may state how or where you would like to be contacted. We may not require that you provide an explanation for your request and will attempt to honor any reasonable requests.
How We may Use and Disclose PHI for Treatment, Payment, and Health Care Operations
For Treatment. Information obtained by LDI will be used to dispense prescription medications to you. We will document in your record information related to the medications dispensed to you and services provided to you.
To Obtain or Provide Payment. If LDI Pharmacy Benefit Management is not your pharmacy benefit manager, the LDI Pharmacy will contact your insurer or pharmacy benefit manager to determine whether it will pay for your prescription and the amount of your co-payment. We will collect from you or will bill a third-party payer the cost of prescription medications dispensed to you. The information on or accompanying the bill may include information that identifies you, as well as the prescriptions you are taking. If LDI Pharmacy Benefit Management is your pharmacy benefit manager we will bill your employer, union, or third party payer for the cost of prescriptions medications dispensed to you. The information on or accompanying the bill may include information that identifies you, as well as the prescriptions you are taking.
To Conduct Health Care Operations. We may use information about you to review the quality of care and services you receive; to provide you case management or care coordination services, such as for asthma, diabetes, and specialty drugs. This information will be used in an effort to continually improve the quality and effectiveness of the health care and service we provide. We may also contact you to provide information about treatment alternatives or other health-related benefits and services. For example, we may notify you that a medication has been recalled or that a generic drug is now available for the brand drug you are using. We may share limited health information with your employer or other organization that helps pay for your membership in the plan or to permit the plan sponsor to perform plan administrative functions. Plan sponsors that receive this information are required by law to have safeguards in place to protect it from inappropriate uses.
How We may Use and Disclose PHI for Treatment, Payment, and Health Care Operations
We may use and disclose PHI about you to provide refill reminders. We may also use and disclose PHI about you to advise you or recommend possible service options or alternatives that may be of interest to you. We may contact you for fundraising activities. However, you will be provided the opportunity to opt out of receiving such fundraising communications.
Disclosures You May Authorize Us to Make
We will not use or disclose PHI about you without authorization, except as described in this Notice. Most uses and disclosures of psychotherapy notes, as applicable, require your authorization. Subject to certain limited exceptions, we may not use or disclose PHI for marketing without your authorization. We may not sell PHI without your authorization. You may give us written authorization to use and/or disclose health information to anyone for any purpose. If you authorize us to use or disclose such information, you may revoke that authorization in writing at any time.
Other Specific Uses or Disclosures
Business associates: There are some services we provide through contracts with business associates. Examples include production of Member ID Cards and the performance of internal audits. When these services are performed, we may disclose PHI about you to our business associate so that they can perform the job we have contracted them to perform. To protect PHI about you, we require each of our business associates to enter into a business associate agreement whereby they agree to appropriately safeguard the PHI.
Communication with individuals involved in your care or payment for your care: Health professionals such as pharmacists, using their professional judgment, may disclose to a family member, other relative, close personal friend or any person you identify, PHI relevant to that person’s involvement in your care or payment related to your care.
Food and Drug Administration (FDA): ): LDI may disclose to the FDA, or persons under the jurisdiction of the FDA, PHI relative to adverse events with respect to drugs, foods, supplements, products and product defects, or post-marketing surveillance information to enable product recalls, repairs, or replacement.
Worker’s compensation: LDI may disclose PHI about you as authorized by and as necessary to comply with laws relating to worker’s compensation or similar programs established by law.
Public health: As required by law, LDI may disclose PHI about you to public health or legal authorities charged with preventing or controlling disease, injury, or disability.
Law enforcement: LDI may disclose PHI about you for law enforcement purposes as required by law or in response to a valid subpoena or other legal process.
As required by law: LDI must disclose PHI about you when required to do so by law.
Health Oversight activities: We may disclose PHI about you to an oversight agency for activities authorized by law. These oversight activities include audits, investigations, and inspections, as necessary for our licensure and for the government to monitor the health care system, government programs, and compliance with civil rights laws.
Judicial and administrative proceedings: If you are involved in a lawsuit or a dispute, we may disclose PHI about you in response to a court or administrative order. We may also disclose PHI about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the requested PHI.
Research: We may disclose PHI about you to researchers under specific limited circumstances, such as when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your information.
Coroners, medical examiners, and funeral directors. We may release PHI about you to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or to determine the cause of death. We may also disclose PHI to funeral directors consistent with applicable law to enable them to carry out their duties.
Organ or tissue procurement organizations: Consistent with applicable law, we may disclose PHI about you to organ procurement organizations or other entities engaged in the procurement, banking, or transplantation of organs for the purpose of tissue donation and transplant.
Notification: We may use or disclose PHI about you to notify or assist in notifying a family members personal representative, or another responsible for your care, your location, and general condition.
Correctional institution: If you are or become an inmate of a correctional institution, we may disclose PHI to the institution or its agents when necessary for your health or the health and safety of others.
To avert a serious threat to health or safety: We may use and disclose PHI about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person.
Military and veterans: If you are a member of the armed forces, we may release PHI about you as required by military command authorities. We may also release PHI about foreign military personnel to the appropriate military authority.
National security and intelligence activities: We may release PHI 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 PHI about you to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state or conduct special investigations.
Victims of abuse, neglect, or domestic violence: We may disclose PHI about you to a government authority, such as a social service or protective services agency, if we reasonably believe you are a victim of abuse, neglect, or domestic violence. We will disclose this type of information only to the extent required by law, if you agree to the disclosure, or if the disclosure is allowed by law and we believe it is necessary to prevent serious harm to you or someone else or the law enforcement or public official that is to receive the report represents that it is necessary and will not be used against you.
For More Information or to Report a Problem
If you have questions or would like additional information about LDI’s privacy practices, you may contact the Privacy Officer at LDI Pharmacy Benefit Management at 701 Emerson Road, Suite 301, Creve Coeur, MO 63141If you believe your privacy rights have been violated, you can file a complaint with the Privacy Officer at LDI Pharmacy Benefit Management. There will be no retaliation for filing a complaint.
You may also file a written complaint with the Secretary of the U.S. Department of Health and Human Services, 200 Independence Avenue SW, Washington, D.C., 20201 or call toll-free (877) 696-6775, by e-mail to OCRComplaint @ hhs.gov, or to Region VII, Office for Civil Rights, U.S. Department of Health and Human Services, 601 East 12th Street - Room 353 Kansas City, MO 64106, Voice Phone (800) 368-1019, FAX (816) 426-3686, TDD (800) 537-7697.
Effective Date - This Notice is effective as of June 1, 2013.
Please sign the following Acknowledgment of Receipt of Notice of Privacy Practices and mail to: Privacy Officer, LDI Pharmacy Benefit Management 701 Emerson Road, Suite 301, Creve Coeur, MO 63141.
LDI Integrated Pharmacy Services
701 Emerson Road, Suite 301
Creve Coeur, Missouri 63141
Acknowledgement of Receipt of Notice of Privacy Practices
I certify that I have received a copy of Notice of Privacy Practices. The Notice of Privacy Practices describes the types of uses and disclosures of my protected health information that might occur in my treatment, payment of my bills or in the performance of LDI's health care operations. The Notice of Privacy Practices also describes my rights and LDI's duties with respect to protected health information about me. The Notice of Privacy Practices is posted in LDI's Pharmacy at 701 Emerson Road, Suite 301, Creve Coeur, MO 63141and also on LDI’s website at www.ldipbm.com.
LDI reserves the right to change its privacy practices that are described in the Notice of Privacy Practices at any time. I may obtain a revised Notice of Privacy Practices by calling the office and requesting a revised copy be sent in the mail, asking for one at the time of my next visit to the pharmacy, or accessing LDI's website.
Signature of Patient or Personal Representative
Name of Patient or Personal Representative
Description of Personal Representative’s Authority
LDI Use Only
Date acknowledgement received: ____________________________________
Reason acknowledgment was not obtained:___________________________________ _____________________________________________________________________