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.
We are required by law to:
Make sure that protected health information is kept private. Protected health information is information that identifies you and relates to your past, present, or future physical or mental health condition and related health care services.
Provide you with this Notice of our legal duties and privacy practices relating to your protected health information. The Notice also describes your rights with respect to protected health information about you.
Follow the terms of the Notice that is currently in effect. We reserve the right to change our practices and this Notice and to make the new Notice effective for all protected health information we maintain. Upon request, we will provide the revised Notice to you.
In some limited situations the law allows or requires us to use or disclose your health information for purposes beyond treatment, payment, and operations. Not all of these situations will apply to us; some may never occur at our health care centers.
As required by law: We must disclose protected health information about you when required to do so by law.
Food and Drug Administration (FDA): We may disclose to the FDA, or persons under the jurisdiction of the FDA, protected health information 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 protected health information about you as authorized by law 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 your protected health information to public health or legal authorities charged with preventing or controlling disease, injury, or disability.
Law enforcement: We may disclose protected health information about you for law enforcement purposes as required by law or in response to a valid subpoena or other legal process.
To avert a serious threat to health or safety: We may use and disclose your protected health information when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person.
Victims of abuse, neglect, or domestic violence: We may disclose your protected health information to public authorities, as allowed, to report suspected abuse, neglect, or domestic violence.
Health oversight activities: We may disclose protected health information about you to an oversight agency for activities authorized by law. These oversight activities include audits, investigations, and inspections, licensure and for the government to monitor the health care system, government programs, and compliance with civil rights laws.
Business associates: There are some services provided by us through contracts with business associates. For example, we may use a collection service for overdue accounts. When we contract these services, we may disclose protected health information about you to our business associates 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 protected health information about you, we require all business associates to appropriately safeguard the protected health information.
Judicial and administrative proceedings: We may disclose your protected health information in the course of any judicial or administrative proceeding, with your consent, or as directed by a court order signed by a judge or as allowed or required by law.
Research: We may disclose protected health information 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 protected health information 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 protected health information consistent with applicable law to funeral directors to carry out their duties.
Organ or tissue procurement organizations: Consistent with applicable law, we may disclose protected health information 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 your protected health information to notify, or assist you in notifying, a family member, personal representative, or another person responsible for your care, about your location and your general condition.
Correctional institution: If you are or become an inmate of a correctional institution, we may disclose protected health information to the institution or its agents when necessary for your health or the health and safety of others.
Military and veterans: If you are a member of the armed forces, we may release protected health information about you as required by military command authorities. We may also release protected health information about foreign military personnel to the appropriate military authority. In addition, we may release your protected health information to help determine eligibility for benefits by the Department of Veterans Affairs.
National security, intelligence activities, and protective services for the President: We may release protected health information about you to authorized federal officials for intelligence, counterintelligence, protective services to the President, and other national security activities authorized by law.
You have the following rights regarding your protected health information.
You may request a restriction on certain uses and disclosures of your protected health information. You have the right to request additional restrictions on our use or disclosure of your protected health information by sending a written request to our Privacy Office. We are not required to agree to those restrictions (except restrictions on disclosures of protected health information to health plans related to payment or health care operations if you have paid the out of pocket amount in full). It is our policy not to grant any other restriction requests.
You may inspect or obtain a copy of your protected health information. You have the right to inspect or obtain a paper or electronic copy of your protected health information that we maintain in a designated record set. The designated record set may include prescription, treatment, and billing records. You may make the request either at our health care center or by sending a written request to our Privacy Office. We may deny your request to inspect and copy in certain limited circumstances. Our policy is to personally deliver or send the records requested to the patient at the address on record for the patient. We may charge a reasonable fee for copies, postage, and supplies (including any electronic media) that are necessary to fulfill the request.
You may request communications of protected health information by alternate methods. You have the right to request that we communicate confidential information to you by an alternate means. For example, you may request that we call you at your work telephone number when your prescription is ready. You must state how or where you would like to be contacted. We will accommodate all reasonable requests that we may require to be in writing.
You may request an amendment to your protected health information. You have the right to request that we change the records that we maintain about you if you feel that the information is incomplete or incorrect. You may make the request either at our health care center or by sending a written request to our Privacy Office. In certain circumstances, we may deny your request for amendment. All denials will be made in writing. If we deny your request, you have the right to file a statement of disagreement with the decision and we may give a rebuttal to your statement.
You may request and receive an accounting of disclosures of your protected health information. You have the right to receive an accounting of the disclosures we have made of your protected health information after April 14, 2003 for most purposes other than treatment, payment, and operations. Such accounting of disclosures for pharmacy patients also excludes disclosures made to you, your family or friends involved in your care, or other disclosures that you authorize. The right to receive an accounting is subject to certain other exceptions, restrictions, and limitations. To request an accounting, make the request at our health care center or send a written request to our Privacy Office.
You may obtain a copy of this Notice. You may ask for a paper copy of this Notice at any time, and one will be provided for you. Copies may be obtained from any of our health care centers.
We will obtain your written authorization before using or disclosing your protected health information for purposes other than those listed in this Notice or as otherwise permitted or required by law. Most uses and disclosures of protected health information for marketing purposes or that constitute a sale of protected health information will require your written authorization. You may revoke an authorization in writing at any time. Upon receipt of the written revocation, we will stop using or disclosing protected health information about you, except to the extent that we have already taken action in reliance on the authorization or required by law.
We will notify you in the event of a breach of unsecured protected health information as defined by law. For More Information or to Report a Problem If you have questions or would like additional information about our privacy practices, you may contact our Privacy Office. If you believe your privacy rights have been violated, you can file a complaint with our Privacy Office and/or with the Secretary of Health and Human Services. We will not retaliate for filing a complaint.
Contact the Privacy Office:
By phone: 1-866-369-HIPA (4472)
In writing: Privacy Office, ShopKo Stores Operating Co., LLC, PO Box 19060, Green Bay, WI 54307-9060, www.shopko.com
Download our Release of Information document.
Effective Date: This Notice is effective as of September 23, 2013. FORM HIPAA 0001-ENG 4/03