The Golub Corporation/Price Chopper/HouseCalls ("Price Chopper") is required by
law to maintain the privacy of Protected Health Information ("PHI") and to provide
individuals 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.
Price Chopper is required to follow the terms of this Notice. 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 may request a 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, you may pick one up at
any Price Chopper Pharmacy location, access our web-site at
www.pricechopper.com or contact Price Chopper's Privacy Officer.
Certain uses and disclosures of PHI require your authorization.
For example, most uses and disclosures of PHI for marketing purposes and
disclosures that constitute a sale of PHI require a written authorization. Except as
outlined below, we will not use or disclose your PHI without your written authorization.
If you have given us an authorization, you may revoke it in writing at any
time, unless we have already acted on it. Once the Privacy Officer receives your
written revocation, it will be effective for future uses and disclosures. Any other
use or disclosure of your PHI not described in this Notice will be made only with
authorization from you.
Request a restriction on certain uses and disclosures of PHI.
You have the right
to request additional restrictions on our use or disclosure of PHI about you by
sending a written request to Price Chopper's Privacy Officer at the address listed
below. We will consider, but are not required to agree to, your restriction request.
For example, you may request a restriction on certain disclosures to your health
plan if the disclosure is purely for carrying out payment or health care operations
and the requested restriction is for services paid out-of-pocket.
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 Price Chopper maintains
the PHI. The designated record set usually will include prescription and billing
records. To inspect or copy PHI about you, you must submit a "Request for Access
to Patient Information" form to a Price Chopper Pharmacy location or mail it to
Price Chopper's Third Party Coordinator. We may charge you a fee after the 1st
initial copy for the costs of copying, mailing and supplies that are necessary to
fulfill your request. We may deny your request to inspect and copy in certain
limited circumstances. If you are denied access to PHI about you, you may request
that the denial be reviewed.
Request a change of PHI.
If you feel that PHI we maintain about you is incomplete
or incorrect, you may request that we change it. You may request a change for as
long as we maintain the PHI. To request a change, you must submit a "Request for
Change" form to a Price Chopper Pharmacy location or to Price Chopper's Third
Party Coordinator. You must include a reason that supports your request. In certain
cases, we may deny your request for change. If we deny your request for change,
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 for Access to Patient
Information" form to Price Chopper's Privacy Officer. Your 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.
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 for Access to
Patient Information" form to a Price Chopper Pharmacy location or to Price
Chopper's Third Party Coordinator. Your request must state how or where you
would like to be contacted. We will accommodate all reasonable requests.
You have the right to be notified in the event we discover a
breach in your unsecured PHI.
Examples of How We May Use and Disclose PHI
The following are descriptions and examples of ways we use and disclose PHI:
We will use PHI for treatment.
Example: Information obtained by the pharmacist
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
We will use PHI for payment.
Example: We 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 bill you or a third-party payor for 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.
We will use PHI for health care operations.
Example: The Pharmacy may use
information in your health record to monitor the performance of the pharmacists
providing treatment to you. This information will be used in an effort to
continually improve the quality and effectiveness of the health care and service we
We are likely to use or disclose PHI for the following purposes:
We work with business associates who perform various
functions on our behalf or provide certain types of services for us. To perform
these functions or to provide the services, the business associate will receive,
maintain, use or disclose information, but only after the business associate
agrees to safeguard appropriately your information as required by law. For example,
we may disclose your information to a business associate to administer
claims or to bill you or your third party payor for services rendered.
Communication with individuals involved in your care or payment for your
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.
We may contact you to provide refill reminders
or information about treatment alternatives or other health-related benefits and
services that may be of interest to you.
We 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.
State and Federal Regulatory Agencies:
We may disclose PHI to federal, state
or local authorities. For example your PHI may be part of a routine audit procedure.
As required by law:
We must disclose PHI about you when required to do so by
Food and Drug Administration (FDA):
We 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.
As required by law, we may disclose PHI about you to public health
or legal authorities charged with preventing or controlling disease, injury, or
We may disclose PHI about you for law enforcement purposes
as required by law or in response to a valid subpoena or other legal process.
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
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.
We are permitted to use or disclose PHI about you for the following purposes:
We may disclose PHI about you to researchers 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 determine the cause of death. Also, we may disclose
PHI to funeral directors consistent with applicable law 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.
We may use or disclose PHI about you in a disaster relief to notify or
assist in notifying a family member, personal representative, or another person
responsible for your care, of your location, your status, and your general condition.
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 official 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 only disclose this type of information 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.
Other Uses and Disclosures of PHI
Price Chopper will obtain your written authorization before using or disclosing PHI
about you for purposes other than those provided for above or as otherwise
permitted or required by law. You may revoke an authorization in writing at any time
by submitting a request to Price Chopper's Privacy Officer. Upon receipt of the
written revocation, we will stop using or disclosing PHI about you, except to the
extent that we have already taken action in reliance on the authorization.
HIPAA Privacy Rules preempted by State Laws
Under federal law, we must not disclose your PHI if it would violate a more
stringent standard in your state. The following is a summary of the applicable state
We will not disclose information about pharmaceutical services rendered to you to
third parties without your consent, except to the following persons:
- the prescribing practitioner or a pharmacist or another prescribing practitioner
presently treating you when deemed medically appropriate;
a nurse who is acting as an agent for a prescribing practitioner that is
presently treating you or a nurse providing care to you in a hospital;
third party payors who pay claims for pharmaceutical services rendered to you
or who have a formal agreement or contract to audit any records or information
in connection with such claims;
any governmental agency with statutory authority to review or obtain such
any individual, the state or federal government or any agency thereof or court
pursuant to a subpoena; and
any individual, corporation, partnership or other legal entity which has a
written agreement with the pharmacy to access the pharmacy's database
provided the information accessed is limited to data which does not identify specific
For Medicaid recipients: We will restrict disclosure of your information to
purposes directly connected with the administration of the Medicaid program.
We will only disclose your professional records if:
Common Electronic File/Database
- we have obtained your permission to do so;
- it is an emergency situation and it is in your best interest for us to disclose
the information; or
- the law requires us to disclose the information.
Price Chopper/HouseCalls Pharmacies share a common database of disbursing
information to better serve our customers. Should you wish to restrict your PHI
to only one store location, please inform your pharmacist or contact the Price
Chopper Privacy Officer.
We will not disclose any HIV-related information, except in situations where the
subject of the information has provided us with a written consent allowing the
release or where we are authorized or required by state or federal law to make the
Follows federal law.
For More Information or to Report a Problem
If you have questions or would like additional information about Price Chopper's
privacy practices, you may contact the Privacy Officer at 461 Nott Street,
Schenectady, NY 12308 or at 518-379-1421. If you believe your privacy rights
have been violated, you can file a complaint by submitting a "Complaint" form to
a Price Chopper Pharmacy location or sending it to Price Chopper's Privacy
Officer or filing it with the Secretary of Health and Human Services. All complaints
must be in writing. There will be no retaliation for filing a complaint.
This Notice is effective as of September 23, 2013.