PRINCE KUHIO PHARMACY NOTICE OF PRIVACY PRACTICES Effective Date: April 14, 2003 NOTICE OF PRIVACY PRACTICE THIS NOTE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. If you have any questions about this notice, please contact: Prince Kuhio Pharmacy Privacy Officer 2330 Kuhio Avenue Honolulu, HI 96815 OUR COMMITMENT TO YOUR PRIVACY Prince Kuhio Pharmacy understands that protected health information about you and your health is personal. We are committed to protecting medical information about you. We create a record of the care and services you receive at this pharmacy. We need this record to provide you with quality care and to comply with certain legal requirements. This Notice of Privacy Practices applies to all of the records the Prince Kuhio Pharmacy creates about you. This notice will tell you about the ways in which Prince Kuhio Pharmacy may use and disclose protected health information about you. We also describe your rights and certain obligations we have regarding the use and disclosure of health information. We are required by law to: 1) Ensure that protected health information that identifies you is kept private; 2) Provide you with a notice of our legal duties and privacy practices with respect to medical information about you; and 3) Follow the terms of the notice that is currently in effect. HOW WE MAY USE AND DISCLOSE PROTECTED HEALTH INFORMATION ABOUT YOU The following categories describe different ways that we use and disclose protected health information. For each category of uses or disclosures we will explain what we mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information will fall within one of the categories. * For treatment. We may use medical information about you to provide you with medical treatment or services. We may disclose medical information about you to doctors, nurses, technicians, medical students, or other personnel who are involved in taking care of you. For example, a doctor prescribing medication for you may need to know what other medications you are taking to protect against harmful interactions. Different department of the pharmacy may also share medical information about you in order to coordinate your treatment. For example, your medical information will be provided to the consultant pharmacist who reviews your treatment. * For Payment. We may use and disclose medical information about you so that the treatment and services you receive at the pharmacy may be billed to and payment may be collected from you, an insurance company, health plan, or a third party billing company. For example, we may need to give your health plan information about a prescription you had filled at this pharmacy so your health plan will pay us or reimburse you. We may also tell your health plan about a prescription that you are going to have filled in order to obtain prior approval or to determine whether your plan will cover the medication. * For Health Care Operations. We may use and disclose medical information about you for pharmacy operations. These uses and disclosures are necessary to run the pharmacy and make sure that all of our patients receive quality care. For example, we may use medical information to review our treatment and services and to evaluate the performance of staff in caring for you. We may also combine medical information about many patients to decide what additional services we should offer or what services are not needed. We may also disclose information about you to pharmacists, technicians, and other personnel for review and learning purposes. * Refill Reminders. We may use and disclose protected health information to contact you as a reminder to refill a prescription. * Treatment Alternatives. We may use and disclose medical information to tell you about or recommend possible treatment options or alternatives that may be of interest to you. * Health Related Benefits and Services. We may use and disclose medical information to tell you about health related benefits or services that may be of interest to you. * As Required By Law. We will disclose medical information about you when required to do so by federal, state, or local law. * To Avert a Serious Threat to Health or Safety. We may use and disclose medical information 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. Any disclosure, however, would only be to someone able to help prevent the threat. SPECIAL SITUATIONS * Organ and Tissue Donation. If you are an organ donor, we may release protected health information to organizations that handle organ procurement or organ, eye or tissue transplantation or to an organ donation bank, as necessary, to facilitate organ or tissue donation and transplantation. * Military and Veterans. If you are a member of the armed forces, we may release medical information about you as required by military command authorities. We may also release medical information about foreign military personnel to the appropriate foreign military authority. * Workers? Compensation. We may release medical information about you for workers? compensation or similar programs. These programs provide benefits for work related injuries or illness. * Public Health Risks. We may disclose medical 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 births and deaths; 3. To report child abuse or neglect 4. To report reactions to medications or problems with products; 5. To notify people of recalls of products they may be using: 6. To notify a person we may have exposed to a disease or may be at risk for contracting or spreading a disease or condition; 7. To notify the appropriate government authority if we believe the patient has been the victim of abuse, neglect or domestic violence. We will only make this disclose if you agree or when required or authorized by law. * Health Oversight Activities. We may disclose medical information to a health oversight agency for activities authorized by law. These oversight activities include for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws. * Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, we may disclose medical information about you in response to a court or administrative order. We may also disclose medical information about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested. * Law Enforcement. We may release medical information if asked to do so by a law enforcement official: a) In response to a court order, subpoena, warrant, summons or similar process; b) To identify or locate a suspect, fugitive, material witness, or missing person; c) About a victim of a crime if, under certain limited circumstances, we are unable to obtain the person?s agreement; d) About a death we believe may be the result of criminal conduct; e) In emergency circumstances to report a crime; the location of the crime or victims; or the identity description or location of the person who committed the crime. * Coroners, medical Examiners and Funeral Directors. We may release medical information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person pr determine the cause of death. We may also release medical information about a patient to funeral directors as necessary to carry out their duties. * National Security and Intelligence Activities. We may also release medical information 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 medical information about you to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state or conduct special investigations. * Inmates. If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release medical information about you to the correctional institution or law enforcement official. This release would be necessary 1) for the institution to provide you with health care; 2) to protect your health and safety or the health and safety of others; or 3) for the safety and security of the correctional institution. YOUR RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOU: You have the following rights regarding medical information we maintain about you: * Right to Inspect and Copy. You have the right to inspect and copy medical information that may be used to make decisions about your care. Usually, this includes medical and billing records, but does not include psychotherapy notes. To inspect and copy medical information that may be used to make decisions about you, you must submit your request in writing to: Privacy Officer, Prince Kuhio Pharmacy, 2330 Kuhio Avenue, Honolulu, HI 96815. If you request a copy of the information, we may charge a fee for the costs of copying, mailing, or other supplies associated with your request. For fee, please write to: Privacy Officer, Prince Kuhio Pharmacy, 2330 Kuhio Avenue, Honolulu, HI 96815. We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to medical information, you may request that the denial be reviewed. Another licensed health care professional chosen by the pharmacy will review your request and the denial. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review. * Right to Amend. If you feel that medical information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information as kept by or for Prince Kuhio Pharmacy. To request an amendment, your request must be made in writing to the Privacy Officer. In addition, you must provide a reason that supports your request. We may deny your request of an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that: 1. Was not created by us, unless the entity that created the information is no longer available to make the amendment; 2. Is not part of the protected health information kept by or for Prince Kuhio Pharmacy; 3. Is not part of the medical information which you would be inspect and copy; 4. Is accurate and complete. * Right to an Accounting of Disclosures. You have the right to request an accounting of disclosures.? This is a list of disclosures we made of medical information about you. To request this list or accounting of disclosures, you must submit your request in writing to: Privacy Officer, Prince Kuhio Pharmacy, 2330 Kuhio Avenue, Honolulu, HI 96815. Your request must state a time period, which may not be longer than six years, and may not include dates before February 26, 2003. Your request should indicate in what form you wand the list (for example, on paper, electronically). The first list you request within a 12-month period will be free. For additional lists, we may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred. * Right to Request Restrictions. You have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment, payment, or healthcare operations. You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend. For example, you could ask that we not use or disclose information about a surgery you had. We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment. To request restrictions, you must make your request in writing to: Privacy Officer, Prince Kuhio Pharmacy, 2330 Kuhio Avenue, Honolulu, HI 96815. In your request, you must tell us 1) what information you want to limit; 2) whether you want to limit our use, disclosure or both; and 3) to whom you want the limits to apply, for example, disclosures to your spouse. * Right to Request Confidential Communications. You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail. To request confidential communications, you must make your request in writing to: Privacy Officer, Prince Kuhio Pharmacy, 2330 Kuhio Avenue, Honolulu, HI 96815. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted. * Right to a Paper Copy of this Notice. You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice. To obtain a paper copy of this notice, please write to: Privacy Officer, Prince Kuhio Pharmacy, 2330 Kuhio Avenue, Honolulu, HI 96815. CHANGES TO THIS NOTICE We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for medical information we already have about you, as well as any information we receive in the future. We will post a copy of the current notice in the pharmacy. The notice will contain an effective date. COMPLAINTS If you believe your privacy rights have been violated, you may file a complaint with the pharmacy or with the Secretary of the Department of Health and Human Services. To file a complaint with the pharmacy contact the Privacy Officer. Our Privacy Officer is responsible for handling complaints. All complaints must be submitted in writing to: Privacy Officer, Prince Kuhio Pharmacy, 2330 Kuhio Avenue, Honolulu, HI 96815. You will not be penalized for filing a complaint. OTHER USES OF MEDICAL INFORMATION Other uses and disclosures of medical information not covered by this notice or the laws that apply to us will be made only with your written permission. If you provide us permission to use or disclose medical information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose medical information about you for the reasons covered by your written authorization.