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PRIVACY POLICY
Please review, print, and return to AmeriPharm with your first
order.
NOTICE OF PRIVACY PRACTICES
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 know that keeping your personal information private is important to you.
That’s why AmeriPharm wants you to know how we protect the information you
share with us.
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AmeriPharm maintains physical, electronic, and procedural safeguards that meet
state and federal regulations. Access to patient information is limited only to
people that need the information for authorized pharmacy purposes.
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AmeriPharm may disclose information when required by law in order to respond to
a subpoena, prevent fraud or comply with an inquiry by a government agency.
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We never share your health information with outside parties for marketing
purposes.
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We never share your health information with a family member unless a written
consent has been signed and is on file with us.
Types of information AmeriPharm collects:
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Information requested on patient order forms including; names, addresses,
credit card information, health conditions and allergies.
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Data pertaining to your prescription profile, such as: name of prescription
medication, strength, dosing instructions, physician’s name.
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Information collected from your health care provider, such as: gender, height,
weight, medical diagnosis. This information is needed in order for AmeriPharm
pharmacists to utilize their clinical expertise while delivering the best
quality of care and is consistent with the patient-doctor-pharmacist
relationship.
AmeriPharm commitment to Privacy:
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Collect only the information we need to help us deliver pharmacy products and
services.
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Prevent unauthorized access to your information, including through the
Internet.
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Refuse to disclose your health information to parties other than AmeriPharm,
for purposes of marketing.
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Refuse to sell your information to outside mailing list companies or
telemarketers.AmeriPharm may contact you by phone to provide refill reminder,
information on treatment alternatives, or other health-related benefits or
services.
Individual Rights
Access - At any time that you need to you can request a copy your
prescription history with AmeriPharm. To do this, simply write to us at
AmeriPharm, PO Box 5736, Sioux Falls SD 57117-5736, be sure to sign and date
the request.
Restriction -You have the right to request that we place additional
restrictions on our use or disclosure of your medical information. We are not
required to agree to these additional restrictions, but if we do, we will abide
by our agreement (except in an emergency). Any agreement to additional
restrictions must be in writing signed by a person authorized to make such an
agreement on our behalf. Mail it to AmeriPharm, PO Box 5736, Sioux Falls SD
57117-5736.
Amendment -You have the right to request that we amend your medical
information. Your request must be in writing, and it must explain why the
information should be amended. We may deny your request if we did not create
the information you want amended and the originator remains available or for
certain other reasons.
Disclosure Accounting – You have the right to receive a list of instances
in which we or our business associates disclosed your medical information for
purposes other than treatment, payment, health care operations, as authorized
by you, and for certain other activities, since April 14, 2003. We will provide
you with the date on which we made the disclosure, the name of the person or
entity to whom we disclosed your medical information, a description of the
medical information we disclosed, the reason for the disclosure, and certain
other information.
Privacy Violation – If you feel that your privacy rights have been
violated you can write to our Privacy Officer. Please indicate what violation
occurred and the date(s) of occurrence. Send this to AmeriPharm, Inc Privacy
Officer PO Box 5736 Sioux Falls SD 57117-5736.
INDIVIDUAL’S SIGNATURE
I, __________________________________________________,
have had full opportunity to read and consider the contents of this
authorization, and I understand that, by signing this form, I am confirming my
authorization of the use and/or disclosure of my protected health information,
as described in this form.
Signature: _____________________________________
Date: ___________________________
If this authorization is signed by a personal representative on behalf of the
individual, complete the following:
Personal Representative’s Name: _______________________________________________
Relationship to Individual: ____________________________________________________
Send completed and signed form to: OR MAIL IN WITH NEXT ORDER
AmeriPharm, Inc
PO Box 5736
Sioux Falls SD 57117-5736
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