Ingles Pharmacy Notice of Privacy Practices

Ingles Pharmacy Notice of Privacy Practices
Effective Date: April 14, 2003

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.

Ingles Markets, Inc. Pharmacy (“Ingles Pharmacy”) understands that your health information is personal. The Ingles Pharmacy is required by law to maintain the privacy of your health information and to provide you with this notice of our legal duties and privacy practices with respect to your health information. Your health information includes the information maintained in your prescription and Pharmacy billing records. This Notice explains how the Ingles Pharmacy may use and disclose your health information and describes your rights with respect to your health information.

How Ingles May Use or Disclose Your Health Information

The law permits the Ingles Pharmacy to use or disclose your health information for the following purposes
without your authorization:

For Treatment. Treatment includes providing, coordinating, or managing your health care. For example, we will use your health information to dispense prescriptions to you. Treatment may also include disclosing your health information to other providers for consultations, drug use review or drug interaction purposes.

For Payment. Payment includes seeking and receiving payment for your filled prescription. For example, we will send a bill to you, your insurance company or another third party for the cost of prescription medications dispensed to you.

For Health Care Operations. Health care operations include activities related to the operation of the Ingles Pharmacy, such as activities designed to improve the quality and effectiveness of the health care and customer service we provide. For example, we may use or disclose your health information to evaluate pharmacist performance.

To Individuals Involved in Your Care. We may disclose your health information to your family members, other relatives, close personal friends or any persons you identify for your care or to receive payment related to your care.

Personal Communications. We may send refill reminders or information about treatment alternatives that may be of interest to you.
As Required by Law. We will disclose health information about you when required to do so by law.

For Public Health Activities. We may disclose health information about you for public health activities. These activities generally include the following: (1) to prevent or control disease, injury or disability; (2) to report adverse reactions to medications or problems with products; (3) to assist in product recalls; and (4) to notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease.

Abuse, Neglect or Domestic Violence. We may notify the appropriate government authority if we believe you are the victim of abuse, neglect or domestic violence. We will only make such disclosures, however, if you agree, or when required or authorized by law.
For Health Oversight Activities. We may disclose your health information to a health oversight agency for activities authorized by law. These oversight activities are necessary for the government to monitor the health care system and may include audits, investigations, inspections and licensure reviews. Judicial and Administrative Proceedings. We may disclose health information about you in response to a court or administrative order. We may also disclose your health information in response to a subpoena, discovery request or other lawful process, but only if reasonable efforts have been made to tell you about the request (which may include written notice to you) or to obtain an order protecting the information requested.

For Law Enforcement Purposes. We may disclose information about you to law enforcement officials, such as the police, to aid in their law enforcement duties.

To Coroners, Medical Examiners, and Funeral Directors. We may release your health information to a coroner or medical examiner to assist them in their duties. We may also release your health information as allowed by law to funeral directors to assist them with their duties.

To Organ, Eye or Tissue Organizations. We may release your health information for purposes of organ, eye or tissue donation and transplant.

For Research Purposes. We may disclose your health information to researchers for certain research studies.

To Avert a Serious Threat to Health and Safety. We may use and disclose your health information to prevent a serious threat to you, another individual, or the public. We will only make such a disclosure to someone in a position to prevent the threat.

For Special Government Functions. We may disclose your health information for special government functions such as the protection of public officials, reporting to various branches of the armed forces, or for national security activities.

For Workers’ Compensation Purposes. We may release your health information where necessary to comply with workers’ compensation laws.

Other Uses and Disclosures of Your Health InformatioN
Except as described in this Notice or otherwise required or allowed by law, the Ingles Pharmacy may not use or disclose your health information for any other purpose without your written authorization. You may revoke your authorization in writing at any time. Once we receive a written revocation, we will stop using and disclosing your health information as requested, except to the extent otherwise required or allowed by law.

All subsidized treatment or operations communication requires your written authorization. Written Authorization is not required for Refill Reminder calls or alerts or sending information in any form to you about a medication you are already taking or have taken. Authorization is also not required in the promotion of general health or required for government programs.

Your Health Information Rights
Right to a Paper Copy of This Notice. You have the right to a paper copy of this notice at any time, which is available at the Pharmacy or online at www.ingles-markets.com. You may also contact the Privacy Officer with the contact information listed below. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice.

Right to Request Restrictions. You have the right to request restrictions on certain uses and disclosures of your health information by completing an Ingles Pharmacy Individual Access Form which is available at the Pharmacy. We are not required to agree to a restriction that you may request. If we agree to your request, we will follow it unless you need emergency treatment. We cannot agree to limit the uses or disclosures of information that are required by law.

Right to Restrict PHI Access to your Health Plan. We may not disclose your PHI to your health plan so as you make the request in writing using the Ingles Pharmacy Individual Access Form and you agree to another form of payment. If the purpose of the disclosure is for treatment, we must submit PHI information to your health plan upon request. You must make a request for restriction on each individual claim you want restricted using the Individual Access Form. If the alternate payment method is insufficient (e.g. – bounced check), we will make a reasonable effort to collect payment from you. If we cannot collect payment from you, we will submit the claim to your Health Plan for payment.

Right to Inspect and Copy. You have the right to inspect and obtain a copy of your health information as long as it is maintained by Ingles Pharmacy. To inspect or copy your health information, submit a written request on the Request to Access and Copy Health Information form, which is available at the Pharmacy. You also may choose to obtain a summary instead of a copy of your health information. We may charge a fee for the costs of copying, mailing or other supplies needed to grant your request. We may deny your request in certain limited circumstances. If you are denied access to your health information, you may request that the denial be reviewed. You have the right to request your PHI in an electronic format. Request for an electronic copy must be made in writing using the Individual Access Form available at the pharmacy, signed by you and must identify to whom the PHI is to be sent. Individuals may designate a recipient of their electronic copy or a hard copy.

Right to Amend. You have the right to request that the Pharmacy amend your health information you consider inaccurate or incomplete. To request an amendment, submit a written request on the Request for Amendment form, which is available at the Pharmacy. In certain circumstances, we may deny your request. We will provide you with information about the procedure for addressing any disagreement you may have with such a denial.

Right to an Accounting Disclosures. You have a right to receive an accounting of any disclosures that we make of your health information after April 14, 2003, except for certain disclosures such as those: (1) for treatment, payment or health care operations; (2) to you or based upon your authorization; or (3) for certain government functions. To request an accounting, submit a written request on the Request for Accounting of Disclosures form, which is available at the Pharmacy.

Right to Request Confidential Communications. You may request communications of your health information by alternative means or at alternative locations by completing a Request for Confidential Communications form, which is available at the Pharmacy. For example, you may request that we contact you about health matters only in writing or at a particular residence or post office box. We will accommodate all reasonable requests.

Changes to Notice of Privacy Practices
We reserve the right to make changes to this Notice and to make the revised Notice effective for health information we already have about you and any information we may receive in the future. Any revised Notice will be posted in the Ingles Pharmacy [or on the website at www.ingles-markets.com]. Upon request, we will provide a revised Notice to you. We are required to follow the terms of the Notice that is currently in effect.

Complaints
If you believe your privacy rights have been violated, you can file a complaint with the Pharmacy Privacy Officer at Ingles Markets, Inc., P.O. Box 6676, Asheville, NC 28816, Attn: Pharmacy Privacy Officer. You may also file a complaint with the Secretary of the Department of Health and Human Services. There will be no retaliation for filing a complaint.

Contact Information
You may submit your requests or questions to the Pharmacy or Pharmacy Privacy Officer at:

Ingles Markets, Inc.
Attn: Pharmacy Privacy Officer
P.O. Box 6676
Asheville, NC 28816

or FAX to 828-669-3685 or 1-800-635-5066