III. Uses and Disclosures Requiring Your Written Authorization

For uses and disclosures of your protected health information beyond treatment, payment and operations purposes, we are required to have your written authorization, except as permitted by law. You have the right to revoke an authorization at any time to stop future uses or disclosures of your information except to the extent that we have already undertaken an action in reliance upon your authorization. Your revocation request must be provided to us in writing. The name, address, telephone number of the person to contact is located on the last page of this document. You may use our Authorization for Use or Disclosure of Protected Health Information form and/or our Revocation of an Authorization form to submit your request to us. Copies of these forms are available at the pharmacy counter.

Examples of uses or disclosures that would require your written authorization include, but are not limited to, the following:

1.        A request to provide your protected health information to an attorney for use in a civil litigation claim.

2.        A request to provide certain information to an insurance or pharmaceutical facility for the purposes of providing you with information relative to insurance benefits or new medications that may be of interest to you.

3.        A request to provide certain information to another individual or facility.

© 2003-2005
Grant County Drugs, Inc