PHI Pharmacy 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 We understand that medical information about you and your health is personal. PHI Pharmacy is required by law to maintain the privacy of your health information, to follow the terms of this Notice, and to provide you with this notice of our legal duties and privacy practices with respect to your health informational. We are required to follow the terms of the Notice that is currently in effect. A paper copy of this notice may be obtained from PHI Pharmacy upon request. How PHI Pharmacy May Use or Disclose Your Health Information PHI Pharmacy protects the privacy of your health information. For some activities, we must have your written authorization to use or disclose your health information. However, the law permits PHI Pharmacy to use or disclose your health information for the following purposes without your authorization.: ? For Treatment. Information obtained by the Pharmacy will be used to dispense prescriptions to you. We may disclose health information about you to pharmacists and other persons who are involved in dispensing your prescription. ? For Payment. We may use and disclose your health information so that your pharmacy services may be billed to, and payment may be collected from you, an insurance company or a third party. ? For Health Care Operations. We may use and disclose health information about you for pharmacy operations. Unless you provide us with alternative instructions, we may send refill reminders and other materials related to your health care to your home. These uses and disclosers are necessary to run the Pharmacy and make sure that you receive quality customer service. ? As Required By Law. We will disclose health 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 health information about you when necessary to prevent a serous 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. ? Public Health Risks. We may disclose health 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 reactions to medications or problems with products; (3) to notify people of recalls of products they may be using; (4) to notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition; and (5) to notify the appropriate government authority if we believe a person has been the victim of abuse, neglect or domestic violence (we will only make this disclosure if you agree and when required or authorized by law). ? For Health Oversight Activities. We may disclose health information to a health oversight agency for activities authorized by law. These oversight activities, which are necessary for the government to monitor the health care system, include audits, investigations, inspections and licensure. ? Lawsuits and Disputes. If you are involved in a lawsuit or dispute, we may disclose health information about you in response to a court order or administrative order. We may also disclose health 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 (which may include written notice to you) or to obtain an order protecting the information requested. ? For Specific Government Functions. PHI Pharmacy may disclose health information for the following specific government functions: (1) health information of military personnel, as required by military command authorities; (2) health information of inmates, to a correctional institution or law enforcement official; (3) in response to a request from law enforcement, if certain conditions are satisfied; and (4) for national security reasons. When PHI Pharmacy May Not Use or Disclose Your Health Information Except as described in this Notice, PHI Pharmacy will not use or disclose your health information without your written authorization. If you do authorize PHI Pharmacy to use or disclose your health information for another purpose, you may revoke your authorization in writing at any time. You Have the Following Rights With Respect to Your Health Information ? You have the right to request restrictions on certain uses and disclosures of your health information. PHI Pharmacy is not required to agree to a restriction that you request. If we do agree to any restriction, we will put the agreement in writing and follow it, except in emergency situation. We cannot agree to limit the uses or disclosures of information that are required by law. ? You have the right to inspect and copy your health information as the Pharmacy maintains the health information. Your health information usually will include prescription and billing records. To inspect or copy your health information, you must submit a written request to PHI Pharmacy. We may charge a fee for the costs of copying, mailing or other supplies that are necessary to grant your request. ? You have the right to request that PHI Pharmacy amend your health information that is incorrect or incomplete. To request an amendment, you must submit a written request to the servicing pharmacy along with the reason for the request. PHI Pharmacy is not required to amend health information that is accurate and complete. PHI Pharmacy will provide you with information about the procedure for addressing any disagreement with a denial. ? You have a right to receive an accounting of disclosures of your health information we have made after April 14, 2003 for purposes other than disclosures (1) for PHI Pharmacy�s treatment, payment or health care operation, (2) to you or based upon your authorization and (3) for certain government functions. To request an accounting, you must submit a written request to the store location providing services. You must specify the time period, which may not be longer than six years. ? You may request communications of your health information by alternative means or at alternative locations. For example, you may request that we contact you about health matters only in writing or at a different residence or post office box. To request confidential communication of your health information, you must submit a written request to PHI Pharmacy. Your request must state how or when you would like to be contacted. We will accommodate all reasonable requests. If you would like to exercise one or more of these rights, contact the store location that provided you services or submit a written request to PHI Pharmacy, Attn: Privacy Officer- P.O. Box 505089, Saipan, MP 96950. Changes to this Notice of Privacy Practices PHI Pharmacy reserves the right to change this Notice. We reserve the right to make the revised or changed Notice effective for health information we already have about you as well as any information we receive in the future. Any revised Notice will be posted in the Pharmacy. Upon request, we will provide a revised Notice to you For More Information or to Report a Problem If you have questions or would like additional information about Pharmacy privacy practices, you may contact, PHI Pharmacy, Attn: Privacy Officer, PO Box 505089, Saipan, MP 96950 or fax 670-235-6180. If you believe your privacy rights have been violated, you can file a complaint with HIPPA Privacy at the above address, or with the Secretary of Health and Human Services. There will be no retaliation for filing a complaint. HIPAA Individual Acknowledgement of Privacy Practices By signing this form, I am indicating that I have been provided a copy of PHI Pharmacy�s Notice of Privacy Practices related to health information. I understand that the Notice is subject to change, and I can obtain a current Notice by contacting PHI Pharmacy. Patient Spouse Guardian Relative Other Print Patient Name Signature Date Relationship (Circle One) HIPAA Individual Acknowledgement of Privacy Practices By signing this form, I am indicating that I have been provided a copy of PHI Pharmacy�s Notice of Privacy Practices related to health information. I understand that the Notice is subject to change, and I can obtain a current Notice by contacting PHI Pharmacy. Patient Spouse Guardian Relative Other Print Patient Name Signature Date Relationship (Circle One) HIPAA Individual Acknowledgement of Privacy Practices By signing this form, I am indicating that I have been provided a copy of PHI Pharmacy�s Notice of Privacy Practices related to health information. I understand that the Notice is subject to change, and I can obtain a current Notice by contacting PHI Pharmacy. Patient Spouse Guardian Relative Other Print Patient Name Signature Date Relationship (Circle One) HIPAA Individual Acknowledgement of Privacy Practices By signing this form, I am indicating that I have been provided a copy of PHI Pharmacy�s Notice of Privacy Practices related to health information. I understand that the Notice is subject to change, and I can obtain a current Notice by contacting PHI Pharmacy. Patient Spouse Guardian Relative Other Print Patient Name Signature Date Relationship (Circle One) HIPAA Individual Acknowledgement of Privacy Practices By signing this form, I am indicating that I have been provided a copy of PHI Pharmacy�s Notice of Privacy Practices related to health information. I understand that the Notice is subject to change, and I can obtain a current Notice by contacting PHI Pharmacy. Patient Spouse Guardian Relative Other Print Patient Name Signature Date Relationship (Circle One) HIPAA Individual Acknowledgement of Privacy Practices By signing this form, I am indicating that I have been provided a copy of PHI Pharmacy�s Notice of Privacy Practices related to health information. I understand that the Notice is subject to change, and I can obtain a current Notice by contacting PHI Pharmacy. Patient Spouse Guardian Relative Other Print Patient Name Signature Date Relationship (Circle One)