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HIPAA Notice of Privacy Practice
CliniCare Pharmacy, Inc. 9663 RESEDA BLVD. NORTHRIDGE, CA 91324 Tel: 818.727.7234 Fax: 818.727.7709 Email: CLINICAREPHARMACY@SBCGLOBAL.NET NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCES TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. In this notice we use the terms “we”, “us,” and “our” to describe CliniCare Pharmacy, Inc. I. WHAT IS “PROTECTED HEATLH INFORMATION?” Your protected health information (PHI) is health information that contains identifies, such as your name, Social Security number, or other information that reveals who you are. For example, your medical record is PHI because it includes your name and other identifiers. II. ABOUT OUR RESPONSIBILITY TO PROTECT YOUR PHI By law, we must 1) Protect the privacy of your PHI, 2) Tell you about your rights and our legal duties with respect to your PHI, and 3) Tell you about our privacy practices and follow our notice currently in effect. We take these responsibilities seriously and, as in the past, we will continue to take appropriate steps to safeguard the privacy of your PHI. In the course of providing health care, we collect various types of PHI from members and patients and other sources, including other health care providers. The medical information may be used, for example, to provide health care services and customer services, evaluate benefits and claims, administer health care coverage, measure performance (utilization review), detect fraud and abuse, review the competence or qualifications of health care professionals, and fulfill legal and regulatory requirements. The types of PHI that we collect and maintain about patients include, for example: * Hospital, medical, mental health, and substance abuse patient records, laboratory results, X-ray reports, and pharmacy records; * Information about your relationship with CliniCare Pharmacy such as: medical services received, claims history, and information from your benefits plans sponsor or employer about group health coverage you may have. III. YOUR RIGHTS REGARDING YOUR PHI This section tells you about your rights regarding your PHI---for example, your medical, pharmacy and billing records. It also describes how you can exercise these rights. Your right to see and receive copies of your PHI In general, you have a right to see and receive copies of your PHI in designated record sets such as your medical and pharmacy record or billing records for as long as we maintain the PHI. If you would like to see or receive a copy of such a record, please write to us. After we receive your written request, we will let you know when and how you can see or obtain a copy of your record. If you agree, we will give you a summary or explanation of your PHI instead of providing copies. We may charge you a fee for the copies, summary or explanation. In limited situations, we may deny some or your entire request to see or receive copies of your records, but if we do, we will tell you why in writing and explain your right, if any, to have our denial reviewed. Your right to choose how we send PHI to you You may ask us to send your PHI to you at a different address (for example, your work address) or by different means (for example, fax instead of regular mail). When we can reasonably and lawfully agree to your request, we will. However, we are permitted to charge you for any additional cost of sending your PHI to a different address or by different means. Your right to correct or update your PHI If you believe there is a mistake in your PHI or important information is missing, you may request that we correct or add to the record. Please write to us and tell us what you are asking for and why we should make the correction or addition. We will respond in writing after receiving your request. If we approve your request, we will make the correction or addition to your PHI. If we deny your request, we will tell you why and explain your right to file a written statement or disagreement. Your statement must be limited to 250 words for each item in your record that you believe is incorrect or incomplete. You must clearly tell us in writing if you want us to include your statement in future disclosures we make of that part of your record. We may include a summary instead of your statement. You may receive an accounting of disclosures of your PHI You may ask us for a list of our disclosures of your PHI. The list we give you will include disclosures made in the last six years, unless you request a shorter time or if less than six years have passed since April 14, 2003. Your request must specify the time period, but may not be longer than six years. You are entitled to one disclosure accounting in any 12-mont period at no charge. If you request any additional accountings less than 12 months later, we may charge a fee. An accounting does not include certain disclosures---for example, disclosures to carry out treatment, payment and health care operations; disclosures that occurred prior to April 14, 2003; disclosures for which CliniCare Pharmacy had a signed authorization; disclosures of your PHI to you; disclosures for notifications for disaster relief purposes; or disclosures to persons involved in your care and persons acting on your behalf. Your right to request limits on uses and disclosures of your PHI You may request that we limit our uses and disclosures if your PHI for treatment, payment and health care operations purposes. However, by law, we do not have to agree to your request. Because we strongly believe that this information is needed to appropriately manage the care of our patients, it is our policy to not agree to requests for restrictions. Your right to receive a paper copy of this notice You also have a right to receive a paper copy of this notice upon request. To provide you with the health care you expect, to treat you, to pay for your care, and to conduct our operations, such as quality assurance, licensing and compliance, CliniCare Pharmacy shares your PHI with its employees. IV. HOW WE MAY SUE AND DISCLOSE YOUR PHI Your confidentiality is important to us. Our employees are required to maintain the confidentiality of the PHI of our patients, and we have policies and procedures and other safeguards to help protect your PHI form improper use and disclosure. Sometimes we are allowed by law to use and disclose certain PHI without your written permission. We briefly describe these uses and disclosures below and give you some examples. How much PHI is used or disclosed without your written permission will vary depending, for example, on the intended purpose of the use or disclosure. Sometimes we may only need to use or disclose a limited amount of PHI, such as to confirm that you are a health plan member with your insurance company. At other times, we may need to use or disclose more PHI, such as when we are providing medical treatment. * Treatment: This is the most important use and disclosure of your PHI. For example, our pharmacists and employees, including trainees, involved in your care use and disclose your PHI to evaluate your condition and your health care needs. Our personnel will use and disclose your PHI in order to provide and coordinate the care and services you need; for example, the 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. If you need care from health care providers who are not part of CliniCare Pharmacy, such as community resources to assist with your health care needs at home, we may disclose your PHI to them. * Treatment alternatives and health-related benefits and services: In some instances, the law permits us to contact you: 1) to describe our network or describe the extent to which we offer and pay for various products and services; 2) for your treatment; 3) for case management and care coordination; or 4) to direct or recommend available treatment options, therapies, health care providers, or care settings. For example, we may tell you about a new drug or about educational or health management activities. * Payment: Your PHI may be needed to permit us to bill and collect payment for, treatment and health-related services that you receive. For example, if you have insurance coverage, we will contact your insurance or pharmacy benefit manager to determine whether it will pay for your prescription and amount of your copayment. We will bill you or the third-party payor for the cost of the prescription medications dispensed to you. The information on or accompanying the bill may include your PHI, as well as the medications you are taking. * Health care operations: We may sue and disclose your HI for certain health care operations---for example, quality assessment and improvement, training and evaluation of health care professionals, such as monitoring 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 services we provide * Business associates: We may contract with business associates to perform certain functions or activities on our behalf, such as payment and health care operations. These business associates must agree to safeguard your PHI. Some of our most common business associates are health and prescription insurance companies, claims processing companies, or legal counsel. * Refill reminders: Your PHI allows us to contact you about refill medications or other health care you may need. * Specific types of PHI: There are stricter requirements for use and disclosure of some types of PHI---for example, mental health and drug and alcohol abuse patient information, HIV tests, and genetic testing information. However, there are still circumstances in which these types of information may be used or disclosed without your authorization. * Communications with family and others when you are present: Sometimes a family member or other person involved in your care will be present when we are discussing your PHI with you. If you object, please tell us and we will not discuss your PHI or we will ask the person to leave. * Communications with family and others when you are not present: There may be times when it is necessary to disclose your PHI to a family member or other person involved in your care because there is an emergency, you are not present, or you lack the decision-making capacity to agree or object. In those instances, we will use our professional judgment to determine if it is in your best interest to disclose your PHI. If so, we will limit the disclosure to the PHI that is directly relevant to the person’s involvement with your health care. For example, we may allow someone to pick up a prescription for you. * Disclosure in case of disaster relief: We may disclose your name, city of residence, age, gender, and general condition to a public or private disaster relief organization to assist disaster relief efforts, unless you object at the time. * Disclosure to parents as personal representatives of minors: In most cases, we may disclose your minor child’s PHI to you. IN some situations, however, we are permitted or even required by law to deny your access to your minor child’s PHI. An example of when we must deny such access based on type of health care is when a minor who is 12 or older seek s care for a communicable disease or condition. Another situation hen we must deny access to parents is when minors have adult rights to make their own health care decisions. These minors include, for example, minors who were or are married or who have a declaration of emancipation from a court. * Research: Research of all kinds may involve the use or disclosure of your PHI. Your PHI can generally be used or disclosed without your permission if an Institutional Review Board (IRB) approves such use or disclosure. AN IRB is a committee that is responsible, under federal law, for reviewing and approving human subjects research to protect the safety of the participants and the confidentiality of the PHI. * Organ Donation: We may use or disclose PHI to organ-procurement organizations to assist with organ, eye or other tissue donations. * Public health activities: Public health activities cover many functions performed or authorized by government agencies to promote and protect the public’s health and may require us to disclose your PHI. -For example, we may disclose your PHI as part of our obligation to report to public health authorities certain diseases, injuries, conditions, and vital events such as births. Sometimes, we may disclose your PHI to someone you may have exposed to a communicable disease or who may otherwise be at risk of getting or spreading the disease. -The Food and Drug Administration (FDA) is responsible for tracking and monitoring certain medical products, such as pacemakers and hip replacements, to identify product problems and failures and injuries they may have caused. If you have received one of these products, we may use and disclose your PHI to the FDA or other authorized persons or organizations such as the maker of the product. -We may use and disclose your PHI as necessary to comply with federal and state laws that govern workplace safety. * Health oversight: As health care providers and health plans, we are subject to oversight conducted by federal and state agencies. These agencies may conduct audits of our operations and activities and in that process, they may review your PHI. * Disclosures to your employer or your employee organization: If you are enrolled in your insurance plan through your employer or employee organization, we may share certain PHI with them without your authorization, but only when allowed by law. For example, we may disclose your PHI for a workers’ compensation claim or to determine whether you are enrolled in the plan or whether premiums have been paid on your behalf. For other purposes, such as for inquiries by your employer or employee organization on your behalf, we will obtain your authorization when necessary under applicable law. * Workers’ compensation: In order to comply with workers’ compensation laws, we may sue and disclose your PHI. For example, we may communicate your medical information regarding a work-related injury or illness to claim administrators, insurance carriers, and others responsible for evaluating your claim for workers’ compensation benefits. * Military activity and national security: We may sometimes use or disclose the PHI of armed forces personnel to the applicable military authorities when they believe it is necessary to properly carry out military missions. We may also disclose your PHI to authorized federal officials as necessary for national security and intelligence activities or for protection of the president and other government officials and dignitaries. * Marketing: We may use and disclose your PHI to contact you about benefits, services, or supplies that we can offer you in addition to your insurance coverage. * Fundraising: we may use or disclose PHI to contact you to raise funds for our organization. * Required by law: In some circumstances federal or state law requires that we disclose your PHI to others. For example, the secretary of the Department of Health and Human Services may review our compliance efforts, which may include seeing your PHI. * Lawsuits and other legal disputes: We may use and disclose PHI in responding to a court administrative order, a subpoena, or discovery request. We may also use and disclose PHI to the extent permitted by law without your authorization, for example, to defend a law suit or arbitration. * Law enforcement: We may disclose PHI to authorized officials for law enforcement purposes, for example, to respond to a search warrant, report a crime on our premises, or help identify or locate someone. * Serious threat to health or safety: We may use and disclose your PHI if we believe it is necessary to avoid a serious threat to your health or safety or to someone else’s. * Abuse or Neglect: By law, we may disclose PHI to appropriate authority to report suspected child abuse or neglect or to identify suspected victims of abuse, neglect or domestic violence. * Corners and funeral directors: we may disclose PHI to a coroner or medical examiner to permit identification of a body, determine cause of death, or for other official duties. WE may also disclose PHI to funeral directors. * Inmates: Under the federal law that requires us to give you this notice, inmates do not have the same rights to control their PHI as other individuals. If you are an inmate of a correctional institution or in the custody of a law enforcement official, we may disclose your PHI to the correctional institution or the law enforcement official for certain purposes, for example, to protect your health or safety of someone else’s. V. ALL OTHER USES AND DISCLOSURES OF YOUR PHI REQUIRE YOUR PRIOR WRITTEN AUTHORIZATION Except for those uses and disclosures described above, we will not use or disclose your PHI without your written authorization. When your authorization is required and you authorize us to use or disclose your PHI for some purpose, you may revoke that authorization by notifying us in writing any time. Please note that the revocation will not apply to any authorized use or disclosure of your PHI that took place before we received your revocation. Also, if you gave your authorization to secure a policy of insurance, including health care coverage from us, you may not be permitted to revoke it until the insurer can no longer contest the policy issued to you or a claim under the policy. VI. HOW TO CONTACT US ABOUT THIS NOTICE OR TO COMPAIN ABOUT OUR PRIVACY PRACTICES If you have any questions about this notice, or want to file a complaint about our privacy practices, please let us know by calling (818)-727-7234. You also may notify the secretary of the Department of Health and Human Services. We will not take retaliatory action against you if you file a complaint about our privacy practices. VII. CHANGES TO THIS NOTICE We may change this notice and our privacy practices at any time, as long as the change is consistent with state and federal law. Any revised notice will apply both to the PHI we already have about you at the time of the change, and any PHI created or received after the change takes effect. If we make an important change t our privacy practices, we will promptly change this notice and provide you with a new notice. Except for changes required by law, we will not implement an important change to our privacy practices before we revise this notice. CLINICARE PHARMACY, INC. CliniCare Pharmacy, Inc. 9663 RESEDA BLVD. NORTHRIDGE, CA 91324 Tel: 818.727.7234 Fax: 818.727.7709 Email: CLINICAREPHARMACY@SBCGLOBAL.NET Name___________________________________________ Last First Last Four Digits of SS#______________________________ PRIVACY PRACTICES ACKNOWLEDGEMENT FORM We have provided you with a Notice of Privacy Practices (“the Notice”) for CliniCare Pharmacy in accordance with federal HIPAA regulations. Please acknowledge that you have received the Notice by signing below. If you have any questions about the Notice of this form, please call us at 1-818-727-7234. Thank you. Patient Signature:___________________________________ Date:_____________________________

About Us

GET TO KNOW YOUR NEIGHBOR. Clinic are Pharmacy has been part of the local community since 2004, serving residents of Northridge and the surrounding area. As an independently owned and operated Good Neighbor Pharmacy, we believe in providing personalized attention, along with a comfortable environment and competitive prices. We take care of our patients and our community. Let us take care of you.

    HIPAA Notice of Privacy Practice
    CliniCare Pharmacy, Inc. 9663 RESEDA BLVD. NORTHRIDGE, CA 91324 Tel: 818.727.7234 Fax: 818.727.7709 Email: CLINICAREPHARMACY@SBCGLOBAL.NET NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCES TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. In this notice we use the terms “we”, “us,” and “our” to describe CliniCare Pharmacy, Inc. I. WHAT IS “PROTECTED HEATLH INFORMATION?” Your protected health information (PHI) is health information that contains identifies, such as your name, Social Security number, or other information that reveals who you are. For example, your medical record is PHI because it includes your name and other identifiers. II. ABOUT OUR RESPONSIBILITY TO PROTECT YOUR PHI By law, we must 1) Protect the privacy of your PHI, 2) Tell you about your rights and our legal duties with respect to your PHI, and 3) Tell you about our privacy practices and follow our notice currently in effect. We take these responsibilities seriously and, as in the past, we will continue to take appropriate steps to safeguard the privacy of your PHI. In the course of providing health care, we collect various types of PHI from members and patients and other sources, including other health care providers. The medical information may be used, for example, to provide health care services and customer services, evaluate benefits and claims, administer health care coverage, measure performance (utilization review), detect fraud and abuse, review the competence or qualifications of health care professionals, and fulfill legal and regulatory requirements. The types of PHI that we collect and maintain about patients include, for example: * Hospital, medical, mental health, and substance abuse patient records, laboratory results, X-ray reports, and pharmacy records; * Information about your relationship with CliniCare Pharmacy such as: medical services received, claims history, and information from your benefits plans sponsor or employer about group health coverage you may have. III. YOUR RIGHTS REGARDING YOUR PHI This section tells you about your rights regarding your PHI---for example, your medical, pharmacy and billing records. It also describes how you can exercise these rights. Your right to see and receive copies of your PHI In general, you have a right to see and receive copies of your PHI in designated record sets such as your medical and pharmacy record or billing records for as long as we maintain the PHI. If you would like to see or receive a copy of such a record, please write to us. After we receive your written request, we will let you know when and how you can see or obtain a copy of your record. If you agree, we will give you a summary or explanation of your PHI instead of providing copies. We may charge you a fee for the copies, summary or explanation. In limited situations, we may deny some or your entire request to see or receive copies of your records, but if we do, we will tell you why in writing and explain your right, if any, to have our denial reviewed. Your right to choose how we send PHI to you You may ask us to send your PHI to you at a different address (for example, your work address) or by different means (for example, fax instead of regular mail). When we can reasonably and lawfully agree to your request, we will. However, we are permitted to charge you for any additional cost of sending your PHI to a different address or by different means. Your right to correct or update your PHI If you believe there is a mistake in your PHI or important information is missing, you may request that we correct or add to the record. Please write to us and tell us what you are asking for and why we should make the correction or addition. We will respond in writing after receiving your request. If we approve your request, we will make the correction or addition to your PHI. If we deny your request, we will tell you why and explain your right to file a written statement or disagreement. Your statement must be limited to 250 words for each item in your record that you believe is incorrect or incomplete. You must clearly tell us in writing if you want us to include your statement in future disclosures we make of that part of your record. We may include a summary instead of your statement. You may receive an accounting of disclosures of your PHI You may ask us for a list of our disclosures of your PHI. The list we give you will include disclosures made in the last six years, unless you request a shorter time or if less than six years have passed since April 14, 2003. Your request must specify the time period, but may not be longer than six years. You are entitled to one disclosure accounting in any 12-mont period at no charge. If you request any additional accountings less than 12 months later, we may charge a fee. An accounting does not include certain disclosures---for example, disclosures to carry out treatment, payment and health care operations; disclosures that occurred prior to April 14, 2003; disclosures for which CliniCare Pharmacy had a signed authorization; disclosures of your PHI to you; disclosures for notifications for disaster relief purposes; or disclosures to persons involved in your care and persons acting on your behalf. Your right to request limits on uses and disclosures of your PHI You may request that we limit our uses and disclosures if your PHI for treatment, payment and health care operations purposes. However, by law, we do not have to agree to your request. Because we strongly believe that this information is needed to appropriately manage the care of our patients, it is our policy to not agree to requests for restrictions. Your right to receive a paper copy of this notice You also have a right to receive a paper copy of this notice upon request. To provide you with the health care you expect, to treat you, to pay for your care, and to conduct our operations, such as quality assurance, licensing and compliance, CliniCare Pharmacy shares your PHI with its employees. IV. HOW WE MAY SUE AND DISCLOSE YOUR PHI Your confidentiality is important to us. Our employees are required to maintain the confidentiality of the PHI of our patients, and we have policies and procedures and other safeguards to help protect your PHI form improper use and disclosure. Sometimes we are allowed by law to use and disclose certain PHI without your written permission. We briefly describe these uses and disclosures below and give you some examples. How much PHI is used or disclosed without your written permission will vary depending, for example, on the intended purpose of the use or disclosure. Sometimes we may only need to use or disclose a limited amount of PHI, such as to confirm that you are a health plan member with your insurance company. At other times, we may need to use or disclose more PHI, such as when we are providing medical treatment. * Treatment: This is the most important use and disclosure of your PHI. For example, our pharmacists and employees, including trainees, involved in your care use and disclose your PHI to evaluate your condition and your health care needs. Our personnel will use and disclose your PHI in order to provide and coordinate the care and services you need; for example, the 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. If you need care from health care providers who are not part of CliniCare Pharmacy, such as community resources to assist with your health care needs at home, we may disclose your PHI to them. * Treatment alternatives and health-related benefits and services: In some instances, the law permits us to contact you: 1) to describe our network or describe the extent to which we offer and pay for various products and services; 2) for your treatment; 3) for case management and care coordination; or 4) to direct or recommend available treatment options, therapies, health care providers, or care settings. For example, we may tell you about a new drug or about educational or health management activities. * Payment: Your PHI may be needed to permit us to bill and collect payment for, treatment and health-related services that you receive. For example, if you have insurance coverage, we will contact your insurance or pharmacy benefit manager to determine whether it will pay for your prescription and amount of your copayment. We will bill you or the third-party payor for the cost of the prescription medications dispensed to you. The information on or accompanying the bill may include your PHI, as well as the medications you are taking. * Health care operations: We may sue and disclose your HI for certain health care operations---for example, quality assessment and improvement, training and evaluation of health care professionals, such as monitoring 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 services we provide * Business associates: We may contract with business associates to perform certain functions or activities on our behalf, such as payment and health care operations. These business associates must agree to safeguard your PHI. Some of our most common business associates are health and prescription insurance companies, claims processing companies, or legal counsel. * Refill reminders: Your PHI allows us to contact you about refill medications or other health care you may need. * Specific types of PHI: There are stricter requirements for use and disclosure of some types of PHI---for example, mental health and drug and alcohol abuse patient information, HIV tests, and genetic testing information. However, there are still circumstances in which these types of information may be used or disclosed without your authorization. * Communications with family and others when you are present: Sometimes a family member or other person involved in your care will be present when we are discussing your PHI with you. If you object, please tell us and we will not discuss your PHI or we will ask the person to leave. * Communications with family and others when you are not present: There may be times when it is necessary to disclose your PHI to a family member or other person involved in your care because there is an emergency, you are not present, or you lack the decision-making capacity to agree or object. In those instances, we will use our professional judgment to determine if it is in your best interest to disclose your PHI. If so, we will limit the disclosure to the PHI that is directly relevant to the person’s involvement with your health care. For example, we may allow someone to pick up a prescription for you. * Disclosure in case of disaster relief: We may disclose your name, city of residence, age, gender, and general condition to a public or private disaster relief organization to assist disaster relief efforts, unless you object at the time. * Disclosure to parents as personal representatives of minors: In most cases, we may disclose your minor child’s PHI to you. IN some situations, however, we are permitted or even required by law to deny your access to your minor child’s PHI. An example of when we must deny such access based on type of health care is when a minor who is 12 or older seek s care for a communicable disease or condition. Another situation hen we must deny access to parents is when minors have adult rights to make their own health care decisions. These minors include, for example, minors who were or are married or who have a declaration of emancipation from a court. * Research: Research of all kinds may involve the use or disclosure of your PHI. Your PHI can generally be used or disclosed without your permission if an Institutional Review Board (IRB) approves such use or disclosure. AN IRB is a committee that is responsible, under federal law, for reviewing and approving human subjects research to protect the safety of the participants and the confidentiality of the PHI. * Organ Donation: We may use or disclose PHI to organ-procurement organizations to assist with organ, eye or other tissue donations. * Public health activities: Public health activities cover many functions performed or authorized by government agencies to promote and protect the public’s health and may require us to disclose your PHI. -For example, we may disclose your PHI as part of our obligation to report to public health authorities certain diseases, injuries, conditions, and vital events such as births. Sometimes, we may disclose your PHI to someone you may have exposed to a communicable disease or who may otherwise be at risk of getting or spreading the disease. -The Food and Drug Administration (FDA) is responsible for tracking and monitoring certain medical products, such as pacemakers and hip replacements, to identify product problems and failures and injuries they may have caused. If you have received one of these products, we may use and disclose your PHI to the FDA or other authorized persons or organizations such as the maker of the product. -We may use and disclose your PHI as necessary to comply with federal and state laws that govern workplace safety. * Health oversight: As health care providers and health plans, we are subject to oversight conducted by federal and state agencies. These agencies may conduct audits of our operations and activities and in that process, they may review your PHI. * Disclosures to your employer or your employee organization: If you are enrolled in your insurance plan through your employer or employee organization, we may share certain PHI with them without your authorization, but only when allowed by law. For example, we may disclose your PHI for a workers’ compensation claim or to determine whether you are enrolled in the plan or whether premiums have been paid on your behalf. For other purposes, such as for inquiries by your employer or employee organization on your behalf, we will obtain your authorization when necessary under applicable law. * Workers’ compensation: In order to comply with workers’ compensation laws, we may sue and disclose your PHI. For example, we may communicate your medical information regarding a work-related injury or illness to claim administrators, insurance carriers, and others responsible for evaluating your claim for workers’ compensation benefits. * Military activity and national security: We may sometimes use or disclose the PHI of armed forces personnel to the applicable military authorities when they believe it is necessary to properly carry out military missions. We may also disclose your PHI to authorized federal officials as necessary for national security and intelligence activities or for protection of the president and other government officials and dignitaries. * Marketing: We may use and disclose your PHI to contact you about benefits, services, or supplies that we can offer you in addition to your insurance coverage. * Fundraising: we may use or disclose PHI to contact you to raise funds for our organization. * Required by law: In some circumstances federal or state law requires that we disclose your PHI to others. For example, the secretary of the Department of Health and Human Services may review our compliance efforts, which may include seeing your PHI. * Lawsuits and other legal disputes: We may use and disclose PHI in responding to a court administrative order, a subpoena, or discovery request. We may also use and disclose PHI to the extent permitted by law without your authorization, for example, to defend a law suit or arbitration. * Law enforcement: We may disclose PHI to authorized officials for law enforcement purposes, for example, to respond to a search warrant, report a crime on our premises, or help identify or locate someone. * Serious threat to health or safety: We may use and disclose your PHI if we believe it is necessary to avoid a serious threat to your health or safety or to someone else’s. * Abuse or Neglect: By law, we may disclose PHI to appropriate authority to report suspected child abuse or neglect or to identify suspected victims of abuse, neglect or domestic violence. * Corners and funeral directors: we may disclose PHI to a coroner or medical examiner to permit identification of a body, determine cause of death, or for other official duties. WE may also disclose PHI to funeral directors. * Inmates: Under the federal law that requires us to give you this notice, inmates do not have the same rights to control their PHI as other individuals. If you are an inmate of a correctional institution or in the custody of a law enforcement official, we may disclose your PHI to the correctional institution or the law enforcement official for certain purposes, for example, to protect your health or safety of someone else’s. V. ALL OTHER USES AND DISCLOSURES OF YOUR PHI REQUIRE YOUR PRIOR WRITTEN AUTHORIZATION Except for those uses and disclosures described above, we will not use or disclose your PHI without your written authorization. When your authorization is required and you authorize us to use or disclose your PHI for some purpose, you may revoke that authorization by notifying us in writing any time. Please note that the revocation will not apply to any authorized use or disclosure of your PHI that took place before we received your revocation. Also, if you gave your authorization to secure a policy of insurance, including health care coverage from us, you may not be permitted to revoke it until the insurer can no longer contest the policy issued to you or a claim under the policy. VI. HOW TO CONTACT US ABOUT THIS NOTICE OR TO COMPAIN ABOUT OUR PRIVACY PRACTICES If you have any questions about this notice, or want to file a complaint about our privacy practices, please let us know by calling (818)-727-7234. You also may notify the secretary of the Department of Health and Human Services. We will not take retaliatory action against you if you file a complaint about our privacy practices. VII. CHANGES TO THIS NOTICE We may change this notice and our privacy practices at any time, as long as the change is consistent with state and federal law. Any revised notice will apply both to the PHI we already have about you at the time of the change, and any PHI created or received after the change takes effect. If we make an important change t our privacy practices, we will promptly change this notice and provide you with a new notice. Except for changes required by law, we will not implement an important change to our privacy practices before we revise this notice. CLINICARE PHARMACY, INC. CliniCare Pharmacy, Inc. 9663 RESEDA BLVD. NORTHRIDGE, CA 91324 Tel: 818.727.7234 Fax: 818.727.7709 Email: CLINICAREPHARMACY@SBCGLOBAL.NET Name___________________________________________ Last First Last Four Digits of SS#______________________________ PRIVACY PRACTICES ACKNOWLEDGEMENT FORM We have provided you with a Notice of Privacy Practices (“the Notice”) for CliniCare Pharmacy in accordance with federal HIPAA regulations. Please acknowledge that you have received the Notice by signing below. If you have any questions about the Notice of this form, please call us at 1-818-727-7234. Thank you. Patient Signature:___________________________________ Date:_____________________________
       
       
       
       
       

    HIPAA Notice of Privacy Practice

    JOSEPH PHARMACY 216 WEST 72ND STREET NEW YORK, NY 10023 TEL (212) 875-1718 FAX (212) 875-0921 E-Mail: JOSEPHPHARMACY@YAHOO.COM OR WWW.JOSEPHPHARMACY.COM NOTICE OF PRIVACY PRACTICES 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. JOSEPH PHARMACY is required by law to maintain the privacy of Protected Health Information ('PHI') and to provide individuals 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 disclose PHI to carry out treatment, payment or health care operations and for other specified purposes that are permitted or required by law. The Notice also describes your rights and with respect to PHI about you. JOSEPH PHARMACY is required to follow the terms of this Notice. We will not use or disclose PHI about you without your written authorization, expect as described in 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, contact the Privacy Officer at (212) 875-1718 or e-mail request to JOSEPHPHARMACY@YAHOO.COM. *Request a restriction on certain uses and disclosures of PHI. You have the right to request additional restrictions on our use and disclosure of PHI about you by sending a written request to the Privacy Officer or e-mailing the request to JOSEPHPHARMACY@YAHOO.COM. We are not required to agree to those restrictions. *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 JOSEPH PHARMACY maintains the PHI. The 'designated record set' usually will include prescription and billing records. To inspect or copy PHI about you, you must send a written request to the Privacy Officer or e-mail it to JOSEPHPHARMACY@YAHOO.COM. We may charge you a fee for the cost 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 an amendment of PHI. If you feel that PHI we maintain about you is incomplete or incorrect, you may request that we amend it. You may request an amendment for as long as we maintain the PHI. To request an amendment, you must send a written request to the Privacy Officer or e-mail it to: JOSEPHPHARMACY@YAHOO.COM. In addition, you must include a reason that supports your request. In certain cases, we may deny your request for an amendment. If we deny your request for amendment, you have the right to file a statement of disagreement with the decision, and we give you a rebuttal to your statement. *Receive an accounting of disclosure 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 disclosures we have made directly to you, 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 in to the Privacy Officer or e-mail it to JOSEPHPHARMACY@YAHOO.COM. 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 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 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 in writing to the Privacy Officer or e-mail it to JOSEPHPHARMACY@YAHOO.COM. Your request must state how or where you would like to be contacted. We will accommodate all reasonable requests. *Revoke your consent to use or disclose PHI. You may revoke consent in writing at any time. Upon receipt of the written revocation, we will stop using or disclosing PHI about you, except to the extent that that we have already taken action in reliance on the consent. We may refuse to continue to treat a customer that revokes his or her consent. Example of How We May Use and Disclose PHI The following categories describe and provide examples of different ways we use and disclose PHI about you. 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 third-party payer 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: JOSEPH 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. We are likely to use or disclose PHI for the following purposes: Business associates: There are some services provided by us through contracts with business associates. Examples include the analysis of prescription costs and their trends for groups and sub- groups of patient populations. When these services are contracted for, we may disclose PHI about you to our business associates so that they can perform the job we have asked them to do and bill you or your third-party payer for services rendered. To protect PHI about you, we require the business associate to appropriately safeguard the PHI. 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 can identify, PHI relevant to that person's involvement in your care or payment related to your care. Personal 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. 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 replacements. Worker's 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. 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 must 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 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 the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the requested PHI. We are permitted to use and disclose PHI about you for the following purposes: Research: We may disclose PHI about you to researchers when an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your information has approved their research. 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. Fundraising: We may contact you as part of a fundraising effort. Notification: We may use or disclose PHI about you to notify or assist in notifying a family member, personal representative, or another person responsible for your care, your location, 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 and 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 or veterans: If you are a member of the armed forces, we may release PHI about you to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law. 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 officials 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 violent: We may disclose PHI about you to a government authority, such as a social service, or protective service 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 of 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 JOSEPH PHARMACY will obtain your written authorization before using or disclosing the PHI about you for purposes other than those provided above or as otherwise permitted or required by law. You may revoke an authorization in writing at any time. 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. For More Information or to Report a Problem If you have questions or would like additional information about Joseph Pharmacy's privacy practices, you may contact our privacy officer. If you believe your privacy right have been violated, you can file a complaint with our HIPAA privacy officer or with the Secretary of Health and Human Services. There will be no retaliation for filing a complaint. Effective Date

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    9245 Reseda Blvd
    Northridge, CA, 91324
    (818) 727-7234

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    Pharmacy Hours

    Mon-Fri: 10:00am - 7:00pm;Sat: 11:00am - 3:00pm;Sun: Closed;

    Store Hours

    Mon-Fri: 10:00am - 7:00pm;Sat: 11:00am - 3:00pm;Sun: Closed;
     
     
     
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    MEDILANE DRUG CORP NOTICE OF PRIVACY PRACTICES 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. LEGAL DUTY We are required by federal and state law to maintain the privacy of your health information. We are also required to give you this notice about our privacy practices, our legal duties and your rights concerning your health information. We must follow the privacy practices that are described in this Notice while it is in effect. This notice takes effect April 14, 2003 and will remain in effect until we replace it. You may request a copy of our Privacy Practice Notice at any time. For more information or additional copies of this Notice, please contact us at the telephone number listed in the Company Information section at the top of this Notice. If and when permitted by applicable law, we have the right to change our privacy practices; if we do so, we will notify you in writing of these changes. USE AND DISCLOSURES OF HEALTH INFORMATION We are permitted by law, to use and disclose health information about you for reasons concerning treatment, payment, and healthcare operations. Examples: Treatment: We may disclose your health information to a physician or healthcare provider that is providing treatment or other healthcare services to you. Payment: We may use and disclose your health information to obtain payment for services that we provide to you. Operations: We may use and disclose your health information in connection with our healthcare operations, which include administration and planning and other tasks that help us improve that quality. Family and Friends: We may disclose your health information to a family member, relative or a friend that has been identified by you while you are present. If you are not present, professional judgment will be utilized to determine whether a disclosure is required or in your best interest. We will only disclose information that is believed to be relevant to the person's involvement with your healthcare of payment related to your health care. We may also disclose your health information in order to notify such persons of your location, general condition or death. As required by law: We must disclose your health information when required to do so by law. Victims of Abuse or Neglect: We may disclose your health information to authorities if reasonable belief is that you are a possible victim of abuse, neglect or domestic violence. We may disclose information to the extent necessary to avert additional serious threat to your health or safety or the health or safety of others. Public Health Activities: We may disclose your health information to public health authorities for the purpose of preventing or controlling disease or preventing injury; to report information to a health oversight agency that is responsible for ensuring compliance with governmental rules and regulations, such as Medicare and Medicaid. National Security: We may disclose to military authorities the health information of Armed Forces personnel under certain circumstances. We may disclose to authorized federal officials health information required for lawful intelligence, counter intelligence, and other national security activities. Appointment Reminders: We may contact you to provide you with appointment reminders, such as voice messages; including essential information such as time, location, and the name of the company/provider. Workers' Compensation: We may use or disclose your health information to the extent necessary to comply with state laws relating to workers' compensation. Disclosures Requiring your Authorization: For any reasons other than those listed in this notice, we may only use or disclose your health information with your written authorization. You authorization must also be obtained prior to using your health information for any marketing activity. YOUR RIGHTS TO YOUR PERSONAL HEALTH INFORMATION Access to Record: You may have access to your health information, with limited exceptions. Request must be made in writing, utilizing our Records Access Request Form. We may charge a reasonable fee to compensate for time and materials. Revocation of your Authorization: You make revoke your authorization to disclose your health information at any time. Request must be made in writing, using our Authorization Revocation form. Restriction of Information: You may request that we place restrictions on our use or disclosure of your health information. You must make you request in writing by sending us a letter that specifies the type of information to be restricted and to whom the information is to be restricted from. Requests should be sent directly to the address listed in the heading of this Notice. We will consider all requests: however are not required to agree to the request. We will respond to all such requests in writing. Disclosure Accounting: You may request a list of instances in which we (or our business associates) disclosed your health information for purposes, other than treatment, payment, healthcare operations and certain other activities, for the last 6 years, but not before April 14, 2003. You must make your request in writing by sending us a letter that specifies the type of information and the time period involved. Requests should be sent directly to the address listed in the heading of this Notice. If you request this information more than once in a 12-month period, we may charge you a reasonable fee to compensate for our time and materials. Alternative Communication: You may request that we communicate with you about your health information by alternative means or to an alternative location. You must make your request in writing by sending a letter that specifies the alternative means of location and provide satisfactory explanation how payments will be handled under the alternative means or location you have requested. Requests should be sent directly to the address listed in the header of this Notice. Amendment: You have the right to request that we amend your health information. You must make your request in writing by sending a letter that explains why the information should be amended. Requests should be sent directly to the address listed in the header of this Notice. We will comply to your request unless we believe that the information to be amended is accurate and complete. Right to Receive Paper Copy of this Notice: Upon request, you may obtain a paper copy of this notice. QUESTIONS OR COMPLAINTS If you are concerned that we may have violated your privacy rights, or if you disagree with a decision we have made about a request for access to your health information, a request you have made to amend or restrict the use or disclosure of your health information or a request you have made for us to communication with your by alternative means or locations, you may complain to us using the contact information listed in the header of this Notice. You may also submit a written complaint to the U.S. Department of Health and Human Services. We will provide you with the address to the U.S. Department of Health and Human Services upon request. If you have any questions, concerns, or complaints about this Notice, please contact us.