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.

The Golub Corporation, Price Chopper, Market 32 and HouseCalls (“Price Chopper”) is required by law to maintain the privacy of Protected Health Information (“PHI”) and to provide you 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 share PHI to carry out treatment, payment or health care operations and for other reasons that are permitted or required by law. The Notice also describes your rights with respect to PHI about
you.

Price Chopper is required to follow the terms of 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 any 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, you may pick one up at any Price Chopper Pharmacy location, access our web-site at pricechopper.com or contact Price Chopper’s Privacy Officer.

Your Authorization: Certain uses and disclosures of PHI require your authorization. For example, most uses and disclosures of PHI for marketing purposes and disclosures that constitute a sale of PHI require a written authorization. Except as outlined below, we will not use or disclose your PHI without your written authorization. If you have given us an authorization, you may revoke it in writing at anytime, unless we have already acted on it. Once the Privacy Officer receives your written revocation, it will be effective for future uses and disclosures. Any other use or disclosure of your PHI not described in this Notice will be made only with authorization from you.

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 Price Chopper’s Privacy Officer at the address listed below. We will consider, but are not required to agree to, your restriction request. For example, you may request a restriction on certain disclosures to your health plan if the disclosure is purely for carrying out payment or health care operations and the requested restriction is for services paid out-of-pocket.

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 Price Chopper maintains the PHI. The designated record set usually will include prescription and billing records. To inspect or copy PHI about you, you must submit a “Request for Access to Patient Information” form to a Price Chopper Pharmacy location or mail it to Price Chopper’s Third Party Coordinator. We may charge you a fee after the 1st initial copy 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 a change of PHI. If you feel that PHI we maintain about you is incomplete or incorrect, you may request that we change it. You may request a change for as long as we maintain the PHI. To request a change, you must submit a “Request for Change” form to a Price Chopper Pharmacy location or to Price Chopper’s Third Party Coordinator. You must include a reason that supports your request. In certain cases, we may deny your request for change. If we deny your request for change, 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 for most purposes other than treatment, payment, or health care operations. The accounting will exclude certain disclosures, such as disclosures 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 receive an accounting is subject to certain other exceptions, restrictions, and limitations. To request an accounting, you must submit a “Request for Access to Patient Information” form to Price Chopper’s Privacy Officer. 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 different residence or post office box. To request confidential communication of PHI about you, you must submit a “Request for Access to Patient Information” form to a Price Chopper Pharmacy location or to Price Chopper’s Third Party Coordinator. Your request must state how or where you would like to be contacted. We will accommodate all reasonable requests.

Breach notification: You have the right to be notified in the event we discover a breach in your unsecured PHI. 

Examples of How We May Use and Disclose PHI

The following are descriptions and examples of ways we use and disclose PHI: 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. Some prescriptions may be filled by a central fill pharmacy or specialty services pharmacy owned by The Company and returned to your local pharmacy for your pick-up. The central fill pharmacy and specialty services pharmacy are located at a different locations than your local pharmacy.  Price Chopper utilizes a secure shared database which allows shared services between our Pharmacies with this notice. Customers may opt out of these shared services by requesting local pharmacy services only at their local Price Chopper.

We will use PHI for health-related communications. Example: The Company’s pharmacies provide a special customer care service to its customers. Under this program, we may contact you, consistent with applicable law, to provide refill reminders or information about treatment alternatives (including the availability of clinical trials) or other health-related benefits and services. If you do not wish to participate in this special care service, you may notify us of this fact at any time in writing, by telephone or in person at one of our stores.

We are likely to use or disclose PHI for the following purposes:

Business associates: We work with business associates who perform various functions on our behalf or provide certain types of services for us. To perform these functions or to provide the services, the business associate will receive, maintain, use or disclose information, but only after the business associate agrees to safeguard appropriately your information as required by law. For example, we may disclose your information to a business associate to administer claims or to bill you or your third party payor for services rendered.

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.

Workers’ 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.

State and Federal Regulatory Agencies: We may disclose PHI to federal, state or local authorities. For example your PHI may be part of a routine audit procedure. As required by law: We must disclose PHI 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, 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.

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.

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.

We are permitted to use or disclose PHI about you for the following purposes:

Research: We may disclose PHI 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 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. Also, we may 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 in a disaster relief to notify or assist in notifying a family member, personal representative, or another person responsible for your care, of your location, your status, 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

Price Chopper 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 by submitting a request to Price Chopper’s Privacy Officer. 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.

HIPAA Privacy Rules preempted by State Laws: Under federal law, we must not disclose your PHI if it would violate a more stringent standard in your state. The following is a summary of the applicable state requirements:

CONNECTICUT

Disclosure

We will not disclose information about pharmaceutical services rendered to you to

third parties without your consent, except to the following persons:

(a) the prescribing practitioner or a pharmacist or another prescribing practitioner presently treating you when deemed medically appropriate;

(b) a nurse who is acting as an agent for a prescribing practitioner that is presently treating you or a nurse providing care to you in a hospital;

(c) third party payors who pay claims for pharmaceutical services rendered to you or who have a formal agreement or contract to audit any records or information in connection with such claims;

(d) any governmental agency with statutory authority to review or obtain such information; 

(e) any individual, the state or federal government or any agency thereof or court pursuant to a subpoena; and

(f) any individual, corporation, partnership or other legal entity which has a written agreement with the pharmacy to access the pharmacy’s database provided the information accessed is limited to data which does not identify specific individuals.

MASSACHUSETTS

Medicaid

For Medicaid recipients: We will restrict disclosure of your information to purposes directly connected with the administration of the Medicaid program.

NEW HAMPSHIRE

Disclosure

We will only disclose your professional records if:  (a) we have obtained your permission to do so;  (b) it is an emergency situation and it is in your best interest for us to disclose the information; or (c) the law requires us to disclose the information.

NEW YORK

Common Electronic File /Database

Price Chopper/HouseCalls Pharmacies share a common database of disbursing information to better serve our customers. Should you wish to restrict your PHI to only one store location, please inform your pharmacist or contact the Price Chopper Privacy Officer.

PENNSYLVANIA

HIV/AIDS

We will not disclose any HIV-related information, except in situations where the subject of the information has provided us with a written consent allowing the release or where we are authorized or required by state or federal law to make the disclosure.

VERMONT

Follows federal law.

For More Information or to Report a Problem

If you have questions or would like additional information about Price Chopper’s privacy practices, you may contact the Privacy Officer at 461 Nott Street, Schenectady, NY 12308 or at 518-379-1421. If you believe your privacy rights have been violated, you can file a complaint by submitting a “Complaint” form to a Price Chopper Pharmacy location or sending it to Price Chopper’s Privacy Officer or filing it with the Secretary of Health and Human Services. All complaints must be in writing. There will be no retaliation for filing a complaint.

Effective Date

This Notice is effective as of September 23, 2013.

Reviewed and Revised October 2018