We may use and disclose your Protected Health Information, without your authorization
when the pharmacy needs to contact a physician or physician’s staff and is permitted
or required to do so without individual written consent or authorization. We may use and
disclose your Protected Health Information if we are contacted by another pharmacy who
states they have your request and consent to transfer pharmacy records to them.
Other uses and disclosures will be made only with your written authorization, and you
may revoke your authorization by notifying us as described in Section B.
2. You may ask us to restrict uses and disclosures of your Protected Health Information
to carry out treatment, payment, or healthcare operations, or to restrict uses and
disclosures to family members, relatives, friends, or other persons identified by you who
are involved in your care or payment for your care. However, we are not required to agree
to your request.
3. You have the right to request the following with respect to your Protected Health
Information: (i) inspection and copying; (ii) amendment or correction; (iii) an accounting
of the disclosures of this information by us; and (iv) the right to receive a paper copy
of this notice upon request.
In addition, you may request, and we must accommodate the request, if reasonable, to
receive communications of Protected Health Information by alternative means or at
alternative locations. To make this request please contact, in writing:
Glenbyrne Pharmacy
1544 So. Byrne Road
Toledo, OH 43614
419-385-5705
4. Unless you object, we may use your name to reference your prescriptions and
pharmaceutical care services. Unless you object, you may be required to sign a
signature log form to acknowledge receipt of service and to consent to disclosure of
Protected Health Information as outlined herein. If you object you will be required to
sign a private affidavit acknowledging services. Your failure to comply could result in
pharmacist’s refusal to provide services. This information may be disclosed by us to
other persons who ask for you or your prescriptions by name. You may restrict or prohibit
these uses and disclosures by notifying a pharmacy representative orally or in writing of
your restriction or prohibition. In the event of an emergency or your incapacity, we will
do what is consistent with your known preference, and what we determine to be in your best
interest. We will inform you of any such uses or disclosures under such circumstances and
give you an opportunity to object as soon as practicable.
5. Unless you object, we may disclose to one of your family members, to a
relative, to a close personal friend, or to any other person identified by you, Protected
Health Information that is directly relevant to the person’s involvement with your
care or payment related to your care. In addition, unless you object, we may use or
disclose the Protected Health Information to notify, identify, or locate a member of your
family, your personal representative, another person responsible for care, or certain
disaster relief agencies of your location, general condition, or death. If you are
incapacitated, there is an emergency, or you object to this use or disclosure, we will do
what in our judgment is in your best interest regarding such disclosure and will disclose
only the information that is directly relevant to the person’s involvement with your
healthcare. We will also use our judgment and experience regarding your best interest in
allowing people to pick-up filled prescriptions, or other similar forms of Protected
Health Information.
6. We reserve the right to change the terms of this notice and to make new notice
provisions effective for all Protected Health Information we maintain. You may receive a
copy of this notice by contacting us as outlined in Section B or upon the receipt of
pharmacy care services.
7. If you believe that your privacy rights have been violated, you may complain to us
at the location described in Section B or to the Secretary of the Department of Health and
Human Services, Hubert H. Humphrey Building, 200 Independence Avenue SW, Washington, DC
20201. You will not be retaliated against for filing a complaint.
