Walde?s Desert Pharmacy 9723 Sierra Vista Rd, Suite E Phelan CA 92371 NOTICE OF PRIVACY PRACTICE 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. If you have any questions about this notice, please contact the pharmacy?s Privacy Officer. Date of Notice: ____________________ This notice describes our pharmacy?s practices of using and disclosing patient information, and that of any health care professional authorized to enter information into your medical record; or all employees, staff and other pharmacy personnel. All of these individuals, entities, sites and locations follow the terms of this notice. In addition, these entities, sites and locations may share medical information with each other for treatment, payment or hospital operations purposes described in this notice. NOTICE: We understand that medical information about you and your health is personal. We are committed to protecting medical information about you. We create a record of the care and services you receive at this pharmacy. We need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by our pharmacy, whether made by personnel or your personal doctor. Your personal doctor may have different policies or notices regarding the doctor's use and disclosure of your medical information created in the doctor's office or clinic. This notice will tell you about the ways in which we may use and disclose medical information about you. We also describe your rights and certain obligations we have regarding the use and disclosure of medical information. We are required by law to: 1) Ensure that medical information that identifies you is kept private; 2) Provide you with a notice of our legal duties and privacy practices with respect to medical information about you; and 3) Follow the terms of the notice that is currently in effect. HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION: The following categories describe different ways that we use and disclose medical information. For each category of uses or disclosures we will explain what we mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information will fall within one of the categories. > For Treatment. We may use medical information about you to provide you with medical treatment or services. We may disclose medical information about you to doctors, nurses, technicians, medical students, or other personnel who are involved in taking care of you. We also may disclose medical information about you to people outside the pharmacy who may be involved in your medical care after you leave the pharmacy, such as family members or others to provide services that are part of your care. > For Payment. We may use and disclose medical information about you so that the treatment and services you receive at the pharmacy may be billed to and payment may be collected from you, an insurance company, health plan or a third-party billing company. For example, we may need to give your health plan information about a prescription you had filled at this pharmacy so your health plan will pay us or reimburse you > For Health Care Operations. We may use and disclose medical information about you for pharmacy operations. These uses and disclosures are necessary to run the pharmacy and make sure that all of our patients receive quality care. For example, we may use medical information to review our treatment and services and to evaluate the performance of our staff in caring for you. We may also combine medical information about many patients to decide what additional services we should offer or what services are not needed. We may also disclose information to doctors, nurses, technicians, medical students, and other personnel for review and learning purposes. We may remove information that identifies you from this set of medical information so others may use it to study health care and health care delivery without learning who the specific patients are. > Treatment Alternatives. We may use and disclose medical information to tell you about or recommend possible treatment options or alternatives that may be of interest to you. > Health-Related Benefits and Services. We may use and disclose medical information to tell you about health-related benefits or services that may be of interest to you. > Individuals Involved in Your Care or Payment for Your Care. We may release medical information about you to a friend or family member who is involved in your medical care. We may also give information to someone who helps pay for your care. > Research. Under certain circumstances, we may use and disclose medical information about you for research purposes. For example, a research project may involve comparing the health and recovery of all patients who received one medication to those who received another, for the same condition. All research projects, however, are subject to a special approval process. This process evaluates a proposed research project and its use of medical information, trying to balance the research needs with patients' need for privacy of their medical information. Before we use or disclose medical information for research, the project will have been approved through this research approval process, but we may, however, disclose medical information about you to people preparing to conduct a research project, for example, to help them look for patients with specific medical needs, so long as the medical information they review does not leave the pharmacy. We will almost always ask for your specific permission if the researcher will have access to your name, address or other information that reveals who you are, or will be involved in your care. > As Required By Law. We will disclose medical information about you when required to do so by federal, state or local law. > To Avert a Serious Threat to Health or Safety. We may use and disclose medical information 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. Any disclosure, however, would only be to someone able to help prevent the threat. > Military and Veterans. If you are a member of the armed forces, we may release medical information about you as required by military command authorities. We may also release medical information about foreign military personnel to the appropriate foreign military authority. > Workers' Compensation. We may release medical information about you for workers' compensation or similar programs. These programs provide benefits for work-related injuries or illness. > Public Health Risks. We may disclose medical information about you for public health activities. These activities generally include the following: * to prevent or control disease, injury or disability; * to report births and deaths; * to report child abuse or neglect; * to report reactions to medications or problems with products; * to notify people of recalls of products they may be using; * to notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition; * to notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect or domestic violence. We will only make this disclosure if you agree or when required or authorized by law. > Health Oversight Activities. We may disclose medical information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws. > Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, we may disclose medical information about you in response to a court or administrative order. We may also disclose medical information about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested. > Law Enforcement. We may release medical information if asked to do so by a law enforcement official: * In response to a court order, subpoena, warrant, summons or similar process; * To identify or locate a suspect, fugitive, material witness, or missing person; * About the victim of a crime if, under certain limited circumstances, we are unable to obtain the person's agreement; * About a death we believe may be the result of criminal conduct; * In emergency circumstances to report a crime; the location of the crime or victims; or the identity, description or location of the person who committed the crime. > Coroners, Medical Examiners and Funeral Directors. We may release medical information 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 release medical information about a patient to funeral directors as necessary to carry out their duties. > National Security and Intelligence Activities. We may release medical information 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 medical information 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. > Inmates. If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release medical information about you to the correctional institution or law enforcement official. This release would be necessary (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) for the safety and security of the correctional institution. YOUR RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOU. You have the following rights regarding medical information we maintain about you: > Right to Inspect and Copy. You have the right to inspect and copy medical information that may be used to make decisions about your care. Usually, this includes medical and billing records, but does not include psychotherapy notes. To inspect and copy medical information that may be used to make decisions about you, you must submit your request in writing. If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other supplies associated with your request. We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to medical information, you may request that the denial be reviewed. Another licensed health care professional chosen by the pharmacy will review your request and the denial. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review. > Right to Amend. If you feel that medical information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by or for the pharmacy. To request an amendment, your request must be made in writing. In addition, you must provide a reason that supports your request. We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that: * Was not created by us, unless the person or entity that created the information is no longer available to make the amendment; * Is not part of the medical information kept by or for the pharmacy; * Is not part of the information which you would be permitted to inspect and copy; or * Is accurate and complete. > Right to an Accounting of Disclosures. You have the right to request an "accounting of disclosures." This is a list of the disclosures we made of medical information about you. To request this list or accounting of disclosures, you must submit your request in writing. Your request must state a time period, which may not be longer than six years, and may not include dates before February 26, 2003. Your request should indicate in what form you want the list (for example, on paper, electronically). The first list you request within a 12-month period will be free. For additional lists, we may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred. > Right to Request Restrictions. You have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment, payment or health care operations. You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend. For example, you could ask that we not use or disclose information about a surgery you had. We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment. To request restrictions, you must make your request in writing. In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit our use, disclosure or both; and (3) to whom you want the limits to apply, for example, disclosures to your spouse. > Right to Request Confidential Communications. You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail. To request confidential communications, you must make your request in writing. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted. > Right to a Paper Copy of This Notice. You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice. CHANGES TO THIS NOTICE We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for medical information we already have about you, as well as any information we receive in the future. We will post a copy of the current notice in the pharmacy. The notice will contain an effective date. We will ask you to sign the notice on your first visit, but we will post revised copies of this notice in the pharmacy. COMPLAINTS If you believe your privacy rights have been violated, you may file a complaint with the pharmacy or with the Secretary of the Department of Health and Human Services. To file a complaint with the pharmacy contact the Privacy Officer. Our Privacy Officer is responsible for handling complaints. All complaints must be submitted in writing. You will not be penalized for filing a complaint. OTHER USES OF MEDICAL INFORMATION. Other uses and disclosures of medical information not covered by this notice or the laws that apply to us will be made only with your written permission. If you provide us permission to use or disclose medical information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose medical information about you for the reasons covered by your written authorization. Patient Acknowledgement of Notice of Privacy Practices I hereby acknowledge receipt of the Notice of Privacy Practice, which explains how this pharmacy may use or disclose protected health information (PHI) about me to other health care organizations, for the purposes of treatment or payment of services. I have reviewed the notice and understand the terms may change. A current notice will be posted in the pharmacy, and a revised copy will be provided at my request. I understand that under HIPAA regulations, I have the right to request that this pharmacy restrict how protected private health information about me is used or disclosed on the Patient Consent form, a document separate from this acknowledgement. By signing this document, I acknowledge that I have received the Notice of Privacy Practices and if I refused to sign this document, I understand that this pharmacy must continue to provide services or treatment. __________________________________________ Patient Name (print) ______________________________________________ ___________________________ Patient Signature Date ______________________________________ ____________________________________ Signature of Legal Guardian (if applicable) Relationship to Patient 1 \\\DC - 68975/1 - #1245136 v1
Welcome to Walde's 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.