This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review this notice carefully.
Dierbergs Pharmacy 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.
Dierbergs’ Pharmacy is required to follow the terms of the Notice that is currently in effect. We will not use or disclose PHI about you without your written authorization, except as described in 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 a 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, contact the pharmacist.
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 the Dierbergs Privacy Officer at 16690 Swingley Ridge Road, Chesterfield, MO 63017. We are not required to agree to those restrictions.
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 the Pharmacy maintains the PHI. The designated record set will include patient history, prescription and billing records. To inspect or copy PHI about you, you must complete a written request form at the pharmacy or send a written request to the Dierbergs Privacy Officer at 16690 Swingley Ridge Road, Chesterfield, MO 63017. We may charge you a fee 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 an amendment of PHI. You may request an amendment of your PHI contained in a designated record set for as long as we maintain the PHI. To request an amendment, you must send a written request to the Dierbergs Privacy Officer at 16690 Swingley Ridge Road, Chesterfield, MO 63017. You must include a reason that supports your request. In certain cases, we may deny your request for amendment. 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 and within six years prior to the date on which the accounting is requested for most purposes other than treatment, payment, or health care operations. The accounting will exclude certain disclosures, such as disclosures we have 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 review an accounting is subject to certain other exceptions, restrictions and limitations. To request an accounting, you much submit a request in writing to the Dierbergs Privacy Officer at 16690 Swingley Ridge Road, Chesterfield, MO 63017. 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 difference residence or post office box. To request confidential communications of PHI about you, you must submit a request in writing to the Dierbergs Privacy Officer at 16690 Swingley Ridge Road, Chesterfield, MO 63017. You must state how or where you would like to be contacted. We will accommodate all reasonable requests.
How We May Use and Disclose PHI
Under the law, we may use or disclose your PHI under certain circumstances without your permission. The following are descriptions and examples of ways we use and disclose PHI. Not every use or disclosure is identified. However, all of the ways we are permitted to use and disclose information will fall within one of the descriptions.
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 to you.
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 provide.
We might use or disclose PHI for the following purposes:
Business associates: There are some services provided by us through contracts with business associates. When these services are contracted for, we may disclose PHI about you to our business associate so that they can perform the job we have asked them to do and bill you or your third-party payor for services rendered. To protect PHI about you, we require the business associate 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.
Health-related communications: 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.
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.
Worker's compensation: 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.
Public health: As required by law, we may disclose PHI about you to public health or legal authorities charged with preventing or controlling disease, injury, or disability.
Law enforcement: 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.
As required by law: We 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.
We are permitted to use or disclose PHI about you for the following purposes:
Research: We may disclose PHI about you to researchers when an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your information has approved their research.
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. We may also 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.
Notification: We may use or disclose PHI about you to notify or assist in notifying a family member, personal representative, or another person responsible for your care, your location, and your 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 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
The Pharmacy 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. 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.
This Notice of Privacy Practices is in addition to Dierbergs’ “Privacy Practices Notice” and “Terms and Conditions of Use” elsewhere in this Website. Please take a few minutes to review those as well. If you browse, shop or perform any other activities via Dierbergs.com, you agree to accept the “Terms and Conditions of Use”. If you do not agree with Dierbergs’ policies regarding privacy practices or if you do not wish to accept the “Terms and Conditions of Use”, please do not use Dierbergs.com.
This Notice is effective as of August 31, 2009.
If you have questions or would like additional information about the Pharmacy's privacy practices, you may contact the Dierbergs Privacy Officer at 16690 Swingley Ridge Road, Chesterfield, MO 63017. If you believe your privacy rights have been violated, you can file a complaint with the Dierbergs' Privacy Officer at (636)532-8884 or with the Secretary of Health and Human Services. There will be no retaliation for filing a complaint.
Dierbergs Markets, Inc.
16690 Swingley Ridge Road
Chesterfield, MO 63017
Acknowledgement and Authorization
Dierbergs Markets is committed to maintaining the privacy of your Protected Health Information (PHI), while providing high quality medical care. In accordance with the Health Insurance Portability and Accountability Act of 1996, today we are presenting to you a full written notice of our privacy practices (v1.0).
Please read the entire document at your convenience. Dierbergs' Pharmacy will not condition any services on the basis of your refusal to sign this authorization. Should you have questions please feel free to contact either the pharmacist or Dierbergs' Privacy Official at (636) 532-8884.
I hereby authorize Dierbergs Markets, Inc. to disclose my PHI consistent with federal & state law and their policies.
Please print out this page using your browser's print option, sign it and mail to:
Dierbergs Privacy Officer
16690 Swingley Ridge Road
Chesterfield, MO, 63017