TOWN PHARMACY 302 S. Prairie Bloomfield, MO 63825 573-568-2643 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. SECTION A: Uses and Disclosures of Protected Health Information 1. Under applicable law, we are required to protect the privacy of your individual health information (information we refer to in this notice as ?Protected Health Information?). We are also required to provide you with this notice regarding our policies and procedures regarding your Protected Health Information and to abide by the terms of this notice, as it may be updated from time to time. We are required to follow the terms of this Notice of Privacy Practices. We will not use or disclose your PHI without your written permission, except as described in this Notice. We reserve the right to change the terms of this Notice and to make the new Notice provisions effective for all PHI we maintain. 2. We may obtain information to dispense prescriptions and for the documentation of pertinent information in your records that may assist us in managing you medication therapy or your overall health. Subject to applicable state law, which is appended in this Notice, the following categories describe different ways that we use and disclose your PHI: FOR TREATMENT PURPOSES, such use and disclosure will take place in providing, coordinating, or managing healthcare and its related services by one or more of your providers, such as when your pharmacist consults with your physician or a specialist regarding your medications, treatment or condition. We may provide refill reminders, health screenings, wellness events, inoculations, vaccinations or information about treatment alternatives or other health related benefits and services that may be of interest to you. FOR PAYMENT PURPOSES, such use and disclosure will take place to obtain or provide reimbursement for providing pharmaceutical care services, such as when your case is reviewed to ensure that appropriate care was rendered. For reimbursement purposes, you Protected Health Information may be disclosed to one or several intermediaries employed by your plan sponsor including but not limited to insurers, pharmacy benefit managers, claims administrators, and computer switching companies. We may also disclose your health information to your plan sponsor. FOR HEALTHCARE OPERATIONS PURPOSES, such use and disclosure will take place in a number of ways, including for quality assessment and improvement, provider review and training, underwriting activities, reviews and compliance activities; planning, development, management, and administration. Your information could be used, for example, to assist in the evaluation of the quality of care that you were provided. In addition, we may contact you for the purpose of fundraising activities. 3. We may use and disclose you Protected Health Information, without your authorization when the pharmacy needs to contact a physician or physician?s staff and is permitted or required to do so without individual written authorization. We may use and disclose your Protected Health Information if we are contacted by another pharmacy who states they have your request and consent to transfer pharmacy records to them. We may employ the services of business associates who may assist us in one or more tasks and who may use, change, or create Protected Health Information. Business associates are required to comply with all the privacy regulations with respect to your PHI. 4. We store some of your PHI in electronic computer files. We back up our electronic records daily, and employ other precautions to safeguard the integrity of your PHI. In spite of the precautions, it is possible, but not likely that computer crash or other technological failure could cause loss of data. In addition, reasonable safeguards are employed to protect your PHI on electronic media. 5. We may disclose to one of your family members, to a relative, to a close friend, or to any other person identified by you, Protected Health Information that is directly relevant to the person?s involvement with your care or payment related to your care. In addition, we may use or disclose the Protected Health Information to notify, identify, or locate a member of your family, your personal representative, another person responsible for care, or certain disaster relief agencies of your location, general condition, or death. If you are incapacitated, there is an emergency, or you object to this use or disclosure, we will do in our judgment what is in your best interest regarding such disclosure and will disclose only the information that is directly relevant to the person?s involvement with your healthcare. We will also use our judgment and experience regarding your best interest in allowing people to pick up filled prescriptions, or other similar forms of Protected Health Information. 6. Subject to applicable state law, which is appended to this Notice, in some limited situations the law allows us or requires us to use or disclose your PHI for purposes beyond treatment, payment, and operations. However, some of the disclosures set forth below may never occur at our pharmacies. 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, food, supplements, products and product defects, or post marketing surveillance information to enable product recalls, repair, or replacement. Workers? Compensation: We may disclose PHI about you as authorized by and as necessary to comply with laws relating to workers? compensation or similar programs established by law. 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. As required by law: We must disclose PHI about you when required to do so by law. 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 law. Judicial and Administrative Proceedings: If you are involved in a lawsuit or 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 by someone else involved in a dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the requested PHI. 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. We may also 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. 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 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. Victims of abuse, neglect, or domestic violence: We may disclose PHI about you to a government Authority 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 or if we believe it is necessary to prevent serious harm to you or someone else. 7. Other uses and disclosures of PHI will be made only with your written authorization and you may revoke your authorization by notifying us in writing as described in Section C. Upon receipt of 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. SECTION B: YOUR RIGHTS WITH RESPECT TO YOUR PROTECTED HEALTH INFORMATION (PHI) The Health Insurance Portability and Accountability Act of 1996 (HIPPA) provides you with several rights related to your PHI. These rights are summarized below. If you would like more information on any of these, please contact our Privacy Officer at the address or telephone number of your pharmacy. 1. You have the right to ask us to restrict uses and disclosures of your PHI to carry out treatment, payment, or healthcare operations, or to restrict disclosures to family members, relatives, friends, or other persons identified by you who are involved in your care or payment for your care. For instance, we may use your name to reference your prescriptions and pharmaceutical care services. You may be required to sign a signature log form to acknowledge receipt of services, to acknowledge receipt of this notice and the disclosure of PHI as outlines herein. This information may be disclosed by us to other persons who ask for you or your prescriptions by name. You may request that we restrict or prohibit these uses and disclosures by notifying a pharmacy representative in writing using a form provided by us. We are not required to honor these requests. We are able to provide treatment services to you even if you object to signing the acknowledgement of this Notice or if we decide not to honor a request regarding your PHI. 2. You have the right to request access to or copies of your PHI; however, we may deny your request in certain limited circumstances. The request must be in writing on a form provided by us, and we may charge you a fee for the costs of copying, mailing and supplies necessary to fulfill your request. 3. If you feel that PHI we maintain about you is incomplete or incorrect, you may request that we amend it. The request must be in writing on a form provided by us, and must include a reason to support the request. If we cannot agree to your requested change, we will notify you in writing as to why we could not agree. You will then have the right to submit to us a written statement of disagreement, to which we may elect to further respond to you. 4. You have the right to receive an accounting of the disclosures we have made of your PHI after April 14, 2003 for most purposes other than treatment, payment, and health care operations. The right to receive an accounting is subject to certain exceptions, restrictions, and limitations. To request an accounting, you must submit a request in writing on a form provided by us. Your request must specify the time period, which may not be longer than six years. 5. You have the right to receive a copy of this Notice upon request, as outlined in section C or upon the receipt of pharmacy care services. 6. You have a right to request that we communicate with you by alternative means or at alternative locations. This request must be made in writing on a form provided by us. We will accommodate all reasonable requests. 7. To make any of these written requests, please contact the pharmacy. 8. If you are a minor who has lawfully provided consent for treatment and you wish for us treat you as an adult for purposes of access to and disclosure of records related to such treatment, please notify the pharmacist. 9. If you believe your privacy rights have been violates, you may complain to us at the location described in Section C or the Secretary of the Department of Health and Human Services. You will not be retaliated against for filing a complaint. SECTION C: CONTACTING US- YOU MAY CONTACT US FOR FURTHER INFORMATION AT: Town Pharmacy- 302 S Prairie- Bloomfield, MO 63825 ? Phone 573-568-2643 Privacy Officer-Heather Finney SECTION D: MISSOURI LAW ADDENDUM: The following state law provisions modify the examples in Section A.2. about how we may use and disclose PHI about you, except as otherwise permitted or required by law: Disclosure/Release Unless authorized by you, we will not release your pharmacy records to anyone other than: (i) you or any other person authorized by you to receive the information; (ii) the authorized prescriber who issued the prescription order, or a licensed health professional who is currently treating you; (iii) in response to lawful requests from a court or grand jury; (iv) a person authorized by a court order; (v) to transfer medical or prescription information between pharmacists as provided by law; or (vi) government agencies acting within the scope of their statutory authority. Medicaid Recipients We will restrict disclosure of your information to purposes directly related to your treatment, for promotion of improved quality of care, and to assist with an investigation, prosecution, or civil or criminal proceeding related to the administration of the Medicaid program.