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:_____________________________
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.