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HIPAA Notice of Privacy Practice
Kovacs-Frey Pharmacy 2860 Artesia Blvd. Redondo Beach, CA 90278 Tel. (310) 371-7541 Fax (310) 542-1488 PRIVACY NOTICE Our organization is dedicated to maintain the privacy of your identifiable health information. In conducting our business, we will create records regarding you and the treatment, products, and services we provide to you. We are required by law to maintain the confidentiality of health information that identifies you. We are also required by law to provide you with this notice of our legal duties and privacy practices concerning your health information. THE FOLLOWING NOTICE DESCRIBES HOW YOUR MEDICAL INFORMATION MAY BE USED AND DISCLOSED, AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW THE INFORMATION CAREFULLY. NOTICE OF PRIVACY PRACTICES As Required by the Privacy Regulations Promulgated Pursuant to the Health Insurance Portability and Accountability Act of 1996 (HIPAA). THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO YOUR IDENTIFIABLE HEALTH INFORMATION. PLEASE REVIEW THIS NOTICE CAREFULLY. OUR COMMITMENT TO YOUR PRIVACY Our organization is dedicated to maintain the privacy of your identifiable health information. In conducting our business, we will create records regarding you and the treatment, products, and services we provide to you. We are required by law to maintain the confidentiality of health information that identifies you. We are also required by law to provide you with this notice of our legal duties and privacy practices concerning your health information. By law, we must follow the terms of the notice of privacy practices that we have in effect at the time. To summarize, this notice provides you with the following important information: How we may use and disclose your identifiable health information Your privacy rights in your identifiable health information Our obligations concerning the use and disclosure of your identifiable health information. The terms of this notice apply to all records containing your identifiable health information that are created or retained by our pharmacy. We reserve the right to revise or amend our notice of privacy practices. Any revision or amendment to this notice will be effective for all of your records our pharmacy has created or maintained in the past, and for any of your records we may create or maintain in the future. Our organization will post a copy of our current notice in our pharmacy in a prominent location, and you may request a copy of our most current notice during any pharmacy visit. IF YOU HAVE QUESTIONS ABOUT THIS NOTICE, PLEASE CONTACT: Compliance Officer, Kovacs Frey Pharmacy 2860 Artesia Blvd Redondo Beach, CA 90278 (310) 371-7541 WE MAY USE AND DISCLOSE YOUR HEALTH INFORMATION IN THE FOLLOWING WAYS The following categories describe the different ways in which we may use and disclose your identifiable health information: Treatment. Our organization may use your identifiable health information to treat you. For example, we may perform a follow-up interview and we may use the results to help us modify your treatment plan. Many of the people who work for our organization may use of disclose your identifiable health information in order to treat you or to assist others in your treatment. Additionally, we may disclose your identifiable health information to others who may assist in your care, such as your physician, therapists, spouse, children, or parents. Payment. Our organization may use and disclose your identifiable health information in order to bill and collect payment for the services and items you may receive from us. For example, we may contact your health insurer to certify that you are eligible for benefits (and for what range of benefits), and we may provide your insurer with details regarding your treatment to determine if your insurer will cover, or pay for, your treatment. We also may use and disclose your identifiable health information to obtain payment from third parties who may be responsible for such costs, such as family members. Also, we may use your identifiable health information to bill you directly for services and items. Health Care Operations. Our organization may use and disclose your identifiable health information to operate our business. As examples of the ways in which we may use and disclose your information for our operations, our organization may use your health information to evaluate the quality of care you received from us or to conduct cost-management and business planning activities for our practice. Appointment Reminders. Our organization may use and disclose your identifiable health information to contact you and remind you of visits/deliveries. Health-Related Benefits and Services. Our organization may use and disclose your identifiable health information to inform you of health-related benefits or services that may be of interest to you. Release of Information to Family/Friends. Our organization may release your identifiable health information to a friend or family member who is helping you pay for your health care or who assists in taking care of you. Disclosures Required by Law. Our organization will use and disclose your identifiable health information when we are required to do so by federal, state, or local law. USE AND DISCLOSURE OF YOUR IDENTIFIABLE HEALTH INFORMATION IN CERTAIN SPECIAL CIRCUMSTANCES The following categories describe unique scenarios in which we may use or disclose your identifiable health information: Public Health Risks. Our organization may disclose your identifiable health information to public health authorities who are authorized by law to collect information for the purpose of: Maintaining vital records, such as births and deaths Reporting child abuse or neglect Preventing or controlling disease, injury, or disability Notifying a person regarding potential exposure to a communicable disease Notifying a person regarding a potential risk for spreading or contracting a disease or condition Reporting reactions to drugs or problems with products or devices Notifying individuals if a product or device they may be using has been recalled Notifying appropriate government agency(ies) and authority(ies) regarding the potential abuse or neglect of an adult patient (including domestic violence); however, we will only disclose this information if the patient agrees or we are required or authorized by law to disclose this information Notifying your employer under limited circumstances related primarily to workplace injury or illness or medical surveillance. Health Oversight Activities. Our organization may disclose your identifiable health information to a health oversight agency for activities authorized by law. Oversight activities can include, for example, investigations, inspections, audits, surveys, licensure, and disciplinary actions; civil, administrative, and criminal procedures or actions; or other activities necessary for the government to monitor government programs, compliance with civil rights laws, and the health care system in general. Lawsuits and Similar Proceedings. Our organization may use and disclose your identifiable health information in response to a court or administrative order if you are involved in a lawsuit or similar proceeding. We may also disclose your identifiable health information in response to a discovery request, subpoena, or other lawful process by another party involved in the dispute, but only if we have made an effort to inform you of the request or to obtain an order protecting the information the party has requested. Law Enforcement. We may release identifiable health information if asked to do so by a law enforcement official: Regarding a crime victim in certain situations, if we are unable to obtain the person?s agreement Concerning a death we believe might have resulted from criminal conduct Regarding criminal conduct at our offices In response to a warrant, summons, court order, subpoena, or similar legal process To identify/locate a suspect, material witness, fugitive, or missing person In an emergency, to report a crime (including the location or victim(s) of the crime, or the description, identity or location of the perpetrator) Serious Threats to Health or Safety. Our organization may use and disclose your identifiable health information when necessary to reduce or prevent a serious threat to your health and safety or the health and safety of another individual or the public. Under these circumstances, we will only make disclosures to a person or organization able to help prevent the threat. Military. Our organization may disclose your identifiable health information if you are a member of U.S. or foreign military forces (including veterans) and if required by the appropriate military command authorities. National Security. Our organization may disclose your identifiable health information to federal officials for intelligence and national security activities authorized by law. We also may disclose your identifiable health information to federal officials in order to protect the President, other officials or foreign heads of state, or to conduct investigations. Inmates. Our organization may disclose your identifiable health information to correctional institutions or law enforcement officials if you are an inmate or under the custody of a law enforcement official. Disclosure for these purposes would be necessary: (a) for the institution to provide health care services to you; (b) for the safety and security of the institution; and/or (c) to protect your health and safety or the health and safety of other individuals. Workers? Compensation. Our organization may release your identifiable health information for workers? compensation and similar programs. YOUR RIGHTS REGARDING YOUR IDENTIFIABLE HEALTH INFORMATION You have the following rights regarding the identifiable health information that we maintain about you: Confidential Communications. You have the right to request that our organization communicate with you about your health and related issues in a particular manner or at a certain location. For instance, you may ask that we contact you at home, rather than work. In order to request a type of confidential communication, you must make a written request to Compliance Officer, Kovacs Frey Pharmacy, 2860 Artesia Blvd, 310-371-7541, specifying the requested method of contact or the location where you wish to be contacted. Our organization will accommodate reasonable requests. You do not need to give a reason for your request. Requesting Restrictions. You have the right to request a restriction in our use or disclosures of your identifiable health information for the treatment, payment, or health care operations. Additionally, you have the right to request that we limit our disclosure of your identifiable health information to individuals involved in your care or the payment for your care, such as family members and friends. We are not required to agree to your request; however, if we do agree, we are bound by our agreement except when otherwise required by law, in emergencies, or when the information is necessary to treat you. In order to request a restriction in our use of disclosure of your identifiable health information, you must make your request in writing to Compliance Officer, Kovacs Frey Pharmacy 2860 Artesia Blvd. Your request must describe in a clear and concise fashion: (a) the information you wish restricted; (b) whether you are requesting to limit our practice?s use, disclosure, or both; and (c) to whom you want the limits to apply. Inspection and Copies. You have the right to inspect and obtain a copy of the identifiable health information that may be used to make decisions about you, including patient medical records and billing records, but not including psychotherapy notes. You must submit your request in writing Compliance Officer, Kovacs Frey Pharmacy, 2860 Artesia Blvd, 310-371-7541 in order to inspect and/or obtain a copy of your identifiable health information. Our organization may charge a fee for the costs of copying, mailing, labor, and supplies associated with your request. Our practice may deny your request to inspect and/or copy in certain limited circumstances; however, you may request a review of our denial. Reviews will be conducted by another licensed health care professional chosen by us. Amendment. You may ask us to amend your health information if you believe it is incorrect or incomplete, and you may request an amendment for as long as the information is kept by or for our organization. To request an amendment, your request must be made in writing and submitted to Compliance Officer, Kovacs Frey Pharmacy, 2860 Artesia Blvd, 310-371-7541. You must provide us with a reason that supports your request for amendment. Our organization will deny your request if you ask us to amend information that is: (a) accurate and complete; (b) not part of the identifiable health information kept by or for the organization; (c) not part of the identifiable health information which you would be permitted to inspect and copy; or (d) not created by our organization, unless the individual or entity that created the information is not available to amend the information. Accounting of Disclosures. All of our patients have the right to requests an ?accounting of disclosures.? An ?accounting of disclosures? is a list of certain disclosures our organization has made of your identifiable health information. In order to obtain an accounting of disclosures, you must submit your request in writing to Compliance Officer, Kovacs Frey Pharmacy, 2860 Artesia Blvd, 310-371-7541. All requests for an ?accounting of disclosures? must state a time period which may not be longer than six years and may not include dates before April 14, 2003. The first list you request within a 12-month period is free of charge, but our practice may charge you for additional lists within the same 12-month period. Our organization will notify you of the costs involved with additional requests, and you may withdraw your request before you incur any costs. Right to a Paper Copy of This Notice. You are entitled to receive a paper copy of our notice of privacy practices. You may ask us to give you a copy of this notice at any time. To obtain a paper copy of this notice, contact Compliance Officer, Kovacs Frey Pharmacy, 2860 Artesia Blvd, 310-371-7541. Right to File a Complaint. If you believe your privacy rights have been violated, you may file a complaint with our organization or with the Secretary of the Department of Health and Human Services. To file a complaint with our organization, Compliance Officer, Kovacs Frey Pharmacy, 2860 Artesia Blvd, 310-371-7541. All complaints must be submitted in writing. You will not be penalized for filing a complaint. Right to Provide an Authorization for Other Uses and Disclosures. Our organization will obtain your written authorization for uses and disclosures that are not identified by this notice or permitted by applicable law. Any authorization you provide to us regarding the use and disclosure of your identifiable health information may be revoked at any time in writing. After you revoke your authorization, we will no longer use or disclose your identifiable health information for the reasons described in the authorization. Please note that we are required to retain records of your care. Kovacs Frey Pharmacy 2860 Artesia Blvd Redondo Beach, CA 90278 (310) 371-7541 Notification of Information Practices The purpose of the consent form is to inform you, the patient, how your personal health information is used and/or disclosed by this provider or organization. We want you to be fully aware of what we do with your information so that you can provide us with your consent in order for us to treat your health care needs, receive payment for services rendered, and allow administrative and other types of health care operations to happen, which are part of normal business activities of the provider or organization. Your consent I understand that as part of my health care, this organization originates and maintains health records describing my health history, symptoms, test results, diagnoses, treatment, and plans for future care or treatment. I understand that this information serves as: 1. A basis for planning my care and treatment. 2. A means of communication among my diagnosis/es and other health information to my bill(s). 3. A source of information for applying my diagnosis/es and other health information to my bill(s). 4. A means by which my health plan or health insurance company can verify that services billed were actually provided. 5. A tool for routine health care operations in this organization, such as ensuring that we have quality processes and programs in place and making sure that the professionals who provide your care and competent to do so. I understand that: 1. I have been provided with a Notice of Information Practices that provides specific examples and descriptions of how my personal health information is used and disclosed by Kovacs Frey Pharmacy; 2. I have the right to review the Notice of Information Practices prior to signing this consent; 3. Kovacs Frey Pharmacy can change its Notice of Information Practices but notify me of those changes before they are put into practice and will mail me a copy of the new Notice to the address that I have provided; 4. I have the right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment or health care operations and that Kovacs Frey Pharmacy is not required to agree to those restrictions; 5. Any restrictions to which Kovacs Frey Pharmacy agrees to will be respected. 6. I may revoke this consent in writing at any time. Further, I am aware that Kovacs Frey Pharmacy can proceed with uses and disclosures that pertain to treatment, payment, or healthcare issues that took place before the consent was revoked.

About Us

Welcome to Kovacs Frey Pharmacy. As your local Good Neighbor Pharmacy, we offer quality products at affordable prices, while providing the personalized attention and customer service you expect from a local business. As your neighbors, we live, work and play in the same community as you and your family. We’re the local business owners you see in the neighborhood, at the school play, and volunteering at the local charity. We believe it is our responsibility to take care of our community and our neighbors, and it’s one we take very seriously. We thrive on the opportunity to serve you and your family to the best of our abilities because your business and your health are very important to us. Get to know your neighbor – we’re here to help.

    HIPAA Notice of Privacy Practice
    Kovacs-Frey Pharmacy 2860 Artesia Blvd. Redondo Beach, CA 90278 Tel. (310) 371-7541 Fax (310) 542-1488 PRIVACY NOTICE Our organization is dedicated to maintain the privacy of your identifiable health information. In conducting our business, we will create records regarding you and the treatment, products, and services we provide to you. We are required by law to maintain the confidentiality of health information that identifies you. We are also required by law to provide you with this notice of our legal duties and privacy practices concerning your health information. THE FOLLOWING NOTICE DESCRIBES HOW YOUR MEDICAL INFORMATION MAY BE USED AND DISCLOSED, AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW THE INFORMATION CAREFULLY. NOTICE OF PRIVACY PRACTICES As Required by the Privacy Regulations Promulgated Pursuant to the Health Insurance Portability and Accountability Act of 1996 (HIPAA). THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO YOUR IDENTIFIABLE HEALTH INFORMATION. PLEASE REVIEW THIS NOTICE CAREFULLY. OUR COMMITMENT TO YOUR PRIVACY Our organization is dedicated to maintain the privacy of your identifiable health information. In conducting our business, we will create records regarding you and the treatment, products, and services we provide to you. We are required by law to maintain the confidentiality of health information that identifies you. We are also required by law to provide you with this notice of our legal duties and privacy practices concerning your health information. By law, we must follow the terms of the notice of privacy practices that we have in effect at the time. To summarize, this notice provides you with the following important information: How we may use and disclose your identifiable health information Your privacy rights in your identifiable health information Our obligations concerning the use and disclosure of your identifiable health information. The terms of this notice apply to all records containing your identifiable health information that are created or retained by our pharmacy. We reserve the right to revise or amend our notice of privacy practices. Any revision or amendment to this notice will be effective for all of your records our pharmacy has created or maintained in the past, and for any of your records we may create or maintain in the future. Our organization will post a copy of our current notice in our pharmacy in a prominent location, and you may request a copy of our most current notice during any pharmacy visit. IF YOU HAVE QUESTIONS ABOUT THIS NOTICE, PLEASE CONTACT: Compliance Officer, Kovacs Frey Pharmacy 2860 Artesia Blvd Redondo Beach, CA 90278 (310) 371-7541 WE MAY USE AND DISCLOSE YOUR HEALTH INFORMATION IN THE FOLLOWING WAYS The following categories describe the different ways in which we may use and disclose your identifiable health information: Treatment. Our organization may use your identifiable health information to treat you. For example, we may perform a follow-up interview and we may use the results to help us modify your treatment plan. Many of the people who work for our organization may use of disclose your identifiable health information in order to treat you or to assist others in your treatment. Additionally, we may disclose your identifiable health information to others who may assist in your care, such as your physician, therapists, spouse, children, or parents. Payment. Our organization may use and disclose your identifiable health information in order to bill and collect payment for the services and items you may receive from us. For example, we may contact your health insurer to certify that you are eligible for benefits (and for what range of benefits), and we may provide your insurer with details regarding your treatment to determine if your insurer will cover, or pay for, your treatment. We also may use and disclose your identifiable health information to obtain payment from third parties who may be responsible for such costs, such as family members. Also, we may use your identifiable health information to bill you directly for services and items. Health Care Operations. Our organization may use and disclose your identifiable health information to operate our business. As examples of the ways in which we may use and disclose your information for our operations, our organization may use your health information to evaluate the quality of care you received from us or to conduct cost-management and business planning activities for our practice. Appointment Reminders. Our organization may use and disclose your identifiable health information to contact you and remind you of visits/deliveries. Health-Related Benefits and Services. Our organization may use and disclose your identifiable health information to inform you of health-related benefits or services that may be of interest to you. Release of Information to Family/Friends. Our organization may release your identifiable health information to a friend or family member who is helping you pay for your health care or who assists in taking care of you. Disclosures Required by Law. Our organization will use and disclose your identifiable health information when we are required to do so by federal, state, or local law. USE AND DISCLOSURE OF YOUR IDENTIFIABLE HEALTH INFORMATION IN CERTAIN SPECIAL CIRCUMSTANCES The following categories describe unique scenarios in which we may use or disclose your identifiable health information: Public Health Risks. Our organization may disclose your identifiable health information to public health authorities who are authorized by law to collect information for the purpose of: Maintaining vital records, such as births and deaths Reporting child abuse or neglect Preventing or controlling disease, injury, or disability Notifying a person regarding potential exposure to a communicable disease Notifying a person regarding a potential risk for spreading or contracting a disease or condition Reporting reactions to drugs or problems with products or devices Notifying individuals if a product or device they may be using has been recalled Notifying appropriate government agency(ies) and authority(ies) regarding the potential abuse or neglect of an adult patient (including domestic violence); however, we will only disclose this information if the patient agrees or we are required or authorized by law to disclose this information Notifying your employer under limited circumstances related primarily to workplace injury or illness or medical surveillance. Health Oversight Activities. Our organization may disclose your identifiable health information to a health oversight agency for activities authorized by law. Oversight activities can include, for example, investigations, inspections, audits, surveys, licensure, and disciplinary actions; civil, administrative, and criminal procedures or actions; or other activities necessary for the government to monitor government programs, compliance with civil rights laws, and the health care system in general. Lawsuits and Similar Proceedings. Our organization may use and disclose your identifiable health information in response to a court or administrative order if you are involved in a lawsuit or similar proceeding. We may also disclose your identifiable health information in response to a discovery request, subpoena, or other lawful process by another party involved in the dispute, but only if we have made an effort to inform you of the request or to obtain an order protecting the information the party has requested. Law Enforcement. We may release identifiable health information if asked to do so by a law enforcement official: Regarding a crime victim in certain situations, if we are unable to obtain the person?s agreement Concerning a death we believe might have resulted from criminal conduct Regarding criminal conduct at our offices In response to a warrant, summons, court order, subpoena, or similar legal process To identify/locate a suspect, material witness, fugitive, or missing person In an emergency, to report a crime (including the location or victim(s) of the crime, or the description, identity or location of the perpetrator) Serious Threats to Health or Safety. Our organization may use and disclose your identifiable health information when necessary to reduce or prevent a serious threat to your health and safety or the health and safety of another individual or the public. Under these circumstances, we will only make disclosures to a person or organization able to help prevent the threat. Military. Our organization may disclose your identifiable health information if you are a member of U.S. or foreign military forces (including veterans) and if required by the appropriate military command authorities. National Security. Our organization may disclose your identifiable health information to federal officials for intelligence and national security activities authorized by law. We also may disclose your identifiable health information to federal officials in order to protect the President, other officials or foreign heads of state, or to conduct investigations. Inmates. Our organization may disclose your identifiable health information to correctional institutions or law enforcement officials if you are an inmate or under the custody of a law enforcement official. Disclosure for these purposes would be necessary: (a) for the institution to provide health care services to you; (b) for the safety and security of the institution; and/or (c) to protect your health and safety or the health and safety of other individuals. Workers? Compensation. Our organization may release your identifiable health information for workers? compensation and similar programs. YOUR RIGHTS REGARDING YOUR IDENTIFIABLE HEALTH INFORMATION You have the following rights regarding the identifiable health information that we maintain about you: Confidential Communications. You have the right to request that our organization communicate with you about your health and related issues in a particular manner or at a certain location. For instance, you may ask that we contact you at home, rather than work. In order to request a type of confidential communication, you must make a written request to Compliance Officer, Kovacs Frey Pharmacy, 2860 Artesia Blvd, 310-371-7541, specifying the requested method of contact or the location where you wish to be contacted. Our organization will accommodate reasonable requests. You do not need to give a reason for your request. Requesting Restrictions. You have the right to request a restriction in our use or disclosures of your identifiable health information for the treatment, payment, or health care operations. Additionally, you have the right to request that we limit our disclosure of your identifiable health information to individuals involved in your care or the payment for your care, such as family members and friends. We are not required to agree to your request; however, if we do agree, we are bound by our agreement except when otherwise required by law, in emergencies, or when the information is necessary to treat you. In order to request a restriction in our use of disclosure of your identifiable health information, you must make your request in writing to Compliance Officer, Kovacs Frey Pharmacy 2860 Artesia Blvd. Your request must describe in a clear and concise fashion: (a) the information you wish restricted; (b) whether you are requesting to limit our practice?s use, disclosure, or both; and (c) to whom you want the limits to apply. Inspection and Copies. You have the right to inspect and obtain a copy of the identifiable health information that may be used to make decisions about you, including patient medical records and billing records, but not including psychotherapy notes. You must submit your request in writing Compliance Officer, Kovacs Frey Pharmacy, 2860 Artesia Blvd, 310-371-7541 in order to inspect and/or obtain a copy of your identifiable health information. Our organization may charge a fee for the costs of copying, mailing, labor, and supplies associated with your request. Our practice may deny your request to inspect and/or copy in certain limited circumstances; however, you may request a review of our denial. Reviews will be conducted by another licensed health care professional chosen by us. Amendment. You may ask us to amend your health information if you believe it is incorrect or incomplete, and you may request an amendment for as long as the information is kept by or for our organization. To request an amendment, your request must be made in writing and submitted to Compliance Officer, Kovacs Frey Pharmacy, 2860 Artesia Blvd, 310-371-7541. You must provide us with a reason that supports your request for amendment. Our organization will deny your request if you ask us to amend information that is: (a) accurate and complete; (b) not part of the identifiable health information kept by or for the organization; (c) not part of the identifiable health information which you would be permitted to inspect and copy; or (d) not created by our organization, unless the individual or entity that created the information is not available to amend the information. Accounting of Disclosures. All of our patients have the right to requests an ?accounting of disclosures.? An ?accounting of disclosures? is a list of certain disclosures our organization has made of your identifiable health information. In order to obtain an accounting of disclosures, you must submit your request in writing to Compliance Officer, Kovacs Frey Pharmacy, 2860 Artesia Blvd, 310-371-7541. All requests for an ?accounting of disclosures? must state a time period which may not be longer than six years and may not include dates before April 14, 2003. The first list you request within a 12-month period is free of charge, but our practice may charge you for additional lists within the same 12-month period. Our organization will notify you of the costs involved with additional requests, and you may withdraw your request before you incur any costs. Right to a Paper Copy of This Notice. You are entitled to receive a paper copy of our notice of privacy practices. You may ask us to give you a copy of this notice at any time. To obtain a paper copy of this notice, contact Compliance Officer, Kovacs Frey Pharmacy, 2860 Artesia Blvd, 310-371-7541. Right to File a Complaint. If you believe your privacy rights have been violated, you may file a complaint with our organization or with the Secretary of the Department of Health and Human Services. To file a complaint with our organization, Compliance Officer, Kovacs Frey Pharmacy, 2860 Artesia Blvd, 310-371-7541. All complaints must be submitted in writing. You will not be penalized for filing a complaint. Right to Provide an Authorization for Other Uses and Disclosures. Our organization will obtain your written authorization for uses and disclosures that are not identified by this notice or permitted by applicable law. Any authorization you provide to us regarding the use and disclosure of your identifiable health information may be revoked at any time in writing. After you revoke your authorization, we will no longer use or disclose your identifiable health information for the reasons described in the authorization. Please note that we are required to retain records of your care. Kovacs Frey Pharmacy 2860 Artesia Blvd Redondo Beach, CA 90278 (310) 371-7541 Notification of Information Practices The purpose of the consent form is to inform you, the patient, how your personal health information is used and/or disclosed by this provider or organization. We want you to be fully aware of what we do with your information so that you can provide us with your consent in order for us to treat your health care needs, receive payment for services rendered, and allow administrative and other types of health care operations to happen, which are part of normal business activities of the provider or organization. Your consent I understand that as part of my health care, this organization originates and maintains health records describing my health history, symptoms, test results, diagnoses, treatment, and plans for future care or treatment. I understand that this information serves as: 1. A basis for planning my care and treatment. 2. A means of communication among my diagnosis/es and other health information to my bill(s). 3. A source of information for applying my diagnosis/es and other health information to my bill(s). 4. A means by which my health plan or health insurance company can verify that services billed were actually provided. 5. A tool for routine health care operations in this organization, such as ensuring that we have quality processes and programs in place and making sure that the professionals who provide your care and competent to do so. I understand that: 1. I have been provided with a Notice of Information Practices that provides specific examples and descriptions of how my personal health information is used and disclosed by Kovacs Frey Pharmacy; 2. I have the right to review the Notice of Information Practices prior to signing this consent; 3. Kovacs Frey Pharmacy can change its Notice of Information Practices but notify me of those changes before they are put into practice and will mail me a copy of the new Notice to the address that I have provided; 4. I have the right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment or health care operations and that Kovacs Frey Pharmacy is not required to agree to those restrictions; 5. Any restrictions to which Kovacs Frey Pharmacy agrees to will be respected. 6. I may revoke this consent in writing at any time. Further, I am aware that Kovacs Frey Pharmacy can proceed with uses and disclosures that pertain to treatment, payment, or healthcare issues that took place before the consent was revoked.
    • Immunization

      Good Neighbor Pharmacy offers a variety of vaccines to keep you healthy. Talk to your pharmacist about the immunizations you may need.

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      Enjoy great cost-savings on your medications, along with the personalized care and service that only your locally owned Good Neighbor Pharmacy can deliver.

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    • Immunizations

      Immunizations are one of the most important ways you can protect yourself and others from serious diseases and infections. The immunization-trained pharmacist at your local Good Neighbor Pharmacy can administer a wide range of immunizations and vaccines, as well as make personalized recommendations that can keep you and your family safe throughout the year.

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    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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    (310) 371-7541

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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.