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HIPAA Notice of Privacy Practice
LONDON DRUG P.O. BOX 325 GRACE, ID 83241 (208) 425-3766 FAX (208) 425-3767 NOTICE OF PRIVACY PRACTICES FOR PROTECTED HEALTH INFORMATION THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLSOED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE READ IT CAREFULLY. This Pharmacy is covered by the medical information privacy provisions of the Health Insurance Portability and Accountability Act of 1996 (generally called ?HIPAA?) and its Regulations. As a result, we are required to comply with HIPAA and the Regulations in the use and disclosure of health information by which our patients can be individually identified. This health information is referred to as ?Protected Health Information? or ?PHI? for short. We are also required under Section 164.250 to give our patients this notice of our legal duties and privacy practices concerning their PHI and also to tell our patients about their rights under HIPAA and the Regulations. 1. USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION There are two categories for the use and disclosure of our patients? PHI: (1) information that we can use and disclose without the patient?s prior consent; and (2) information that we cannot use or disclose without the patient?s prior authorization. A. PATIENTS? PRIOR CONSENT NOT REQUIRED 1) Treatment. In the first category, we are permitted to use and disclose our patients? PHI in connection with their medical treatment in situations such as allowing a family member or other relative or a close personal friend or other person involved in the patient?s health care to pick the patient?s prescriptions and to receive Protected Health Information that is directly related to the patient?s care. In doing so, we are to use our professional judgment and experience with common practice in determining what is in the patient?s best interest. Other examples in clued sending information about a patient?s prescriptions to the patient?s family doctor or to a specialist who is treating the patient or to a hospital where the patient is receiving care, particularly if the patient has suffered a health emergency. 2) Payment. If a patient is covered by a pharmacy benefit plan, we are entitled to send PHI to the plan describing the medications or health care equipment we have dispensed so that we can be paid. 3) Health Care Operations. In addition, we can provide PHI for health care operations such as evaluations of the quality of our patients? health care in order improve the success of treatment programs. Other examples include review of health care professionals, insurance premium rating, legal and auditing functions, and business planning and management. 4) Other Permitted Uses and Disclosures. There are a number of other specified purposes for which we may disclose a patient?s PHI without the patient?s prior consent (but with certain restrictions). Examples include public health activities; situations where there may b abuse, neglect or domestic violence; in connection with health oversight activities; in the course of judicial or administrative proceedings; in response to law enforcement inquiries; in the event of death; where organ donations are involved; in support of research studies; where there is a serious threat to health and safety; in cases of military or veterans? activities; where national security is involved; for determinations of medical suitability; for government programs for public benefit; for workers? compensation proceedings; when our records are being audited; when medical emergencies occur; and when we command meeting with our patients orally or in writing about refilling prescriptions, about generic drugs that may be appropriate for a patient?s treatment, or about alternative therapies. B. PATIENT?S PRIOR AUTHORIZATION REQUIRED For purposes other than those mentioned above, we are required to ask for our patients? written authorizations before using or disclosing any of their PHI. If we request an authorization, any of our patients may decline to agree, and if a patient gives us an authorization, the patient has the right to revoke the authorization and by doing so, stop any future uses and disclosures of the patient?s health information that the authorization covered. An example of a situation where the patient?s prior authorization would be required would be if we wish to conduct a marketing program that would involve the use of PHI. 2. PATIENTS? RIGHTS HIPAA and the Regulations provide our patients with rights concerning their PHI. With limited exceptions (which are subject to review) each patient has the right to the following: (a) Patient?s Record. Each patient can obtain a copy of his or her PHI by completing our request form. The only charge will be based on our cost in responding to the request. The amount of the charge will vary depending on the format the patient requests and whether the patient wants the record or a summary, and whether it is to be delivered by mail or otherwise. The patient will be told of the fee when the patient?s request is received. (b) Accounting for Disclosures. By completing our request form, each patient is entitled to obtain a list of the disclosures of the patient?s PHI that have occurred within a period of 6 years after April 14, 2003, except for disclosures made for the purposes of treatment, payment or health care operations and certain others. There will be no charge for the first request in any 12 month period, but we are entitled to charge a reasonable cost based fee for additional request made in the same time period of time. (c) Amendments. Each patient may ask to change the record of his or her own PHI by completing our request form explaining why the change should be made. WE will review the request, but may decline to make the change if in our professional judgment we conclude that the record should not be changed. (d) Communications. By completing our request form, each patient can ask us to communicate with him or her about their own PHI in a confidential manner such as by sending mail to an address other than the home address or using a particular telephone number. (e) Special Restrictions. By completing our request form, each pateitn can ask us to adopt special restrictions that further limit our use and disclosure of the patient?s PHI (except where use and disclosure are required of us by law or in emergency circumstances). We will consider the request; but in accordance with HIPAA and the Regulations, we are not required to agree with the request. (f) Complaints. If a patient believes that we have violated the patient?s rights as to the patient?s PHI under HIPAA and the Regulations, or if a patient disagrees with a decision we made about access to the patient?s PHI, the patient has the right to complete our complaint form and deliver it to our Contact Person listed below. Our Contact Person is required to investigate, and if possible, to resolve each such complaint, and to advise the patient accordingly. The patient also has the right to send a written complaint to the U.S. Department of Health and Human Services. Under no circumstances will any patient be retaliated against by this Pharmacy for filing a complaint. We are required by law to protect the privacy of our patients? PHI, to provide this notice about our practices, and follow the privacy practices that are described in this notice. We reserve the right to make changes in our privacy practices that will apply to the entire PHI we maintain. A new notice will be available on request before any significant change is made.

About Us

Welcome to London Drug. 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
    LONDON DRUG P.O. BOX 325 GRACE, ID 83241 (208) 425-3766 FAX (208) 425-3767 NOTICE OF PRIVACY PRACTICES FOR PROTECTED HEALTH INFORMATION THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLSOED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE READ IT CAREFULLY. This Pharmacy is covered by the medical information privacy provisions of the Health Insurance Portability and Accountability Act of 1996 (generally called ?HIPAA?) and its Regulations. As a result, we are required to comply with HIPAA and the Regulations in the use and disclosure of health information by which our patients can be individually identified. This health information is referred to as ?Protected Health Information? or ?PHI? for short. We are also required under Section 164.250 to give our patients this notice of our legal duties and privacy practices concerning their PHI and also to tell our patients about their rights under HIPAA and the Regulations. 1. USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION There are two categories for the use and disclosure of our patients? PHI: (1) information that we can use and disclose without the patient?s prior consent; and (2) information that we cannot use or disclose without the patient?s prior authorization. A. PATIENTS? PRIOR CONSENT NOT REQUIRED 1) Treatment. In the first category, we are permitted to use and disclose our patients? PHI in connection with their medical treatment in situations such as allowing a family member or other relative or a close personal friend or other person involved in the patient?s health care to pick the patient?s prescriptions and to receive Protected Health Information that is directly related to the patient?s care. In doing so, we are to use our professional judgment and experience with common practice in determining what is in the patient?s best interest. Other examples in clued sending information about a patient?s prescriptions to the patient?s family doctor or to a specialist who is treating the patient or to a hospital where the patient is receiving care, particularly if the patient has suffered a health emergency. 2) Payment. If a patient is covered by a pharmacy benefit plan, we are entitled to send PHI to the plan describing the medications or health care equipment we have dispensed so that we can be paid. 3) Health Care Operations. In addition, we can provide PHI for health care operations such as evaluations of the quality of our patients? health care in order improve the success of treatment programs. Other examples include review of health care professionals, insurance premium rating, legal and auditing functions, and business planning and management. 4) Other Permitted Uses and Disclosures. There are a number of other specified purposes for which we may disclose a patient?s PHI without the patient?s prior consent (but with certain restrictions). Examples include public health activities; situations where there may b abuse, neglect or domestic violence; in connection with health oversight activities; in the course of judicial or administrative proceedings; in response to law enforcement inquiries; in the event of death; where organ donations are involved; in support of research studies; where there is a serious threat to health and safety; in cases of military or veterans? activities; where national security is involved; for determinations of medical suitability; for government programs for public benefit; for workers? compensation proceedings; when our records are being audited; when medical emergencies occur; and when we command meeting with our patients orally or in writing about refilling prescriptions, about generic drugs that may be appropriate for a patient?s treatment, or about alternative therapies. B. PATIENT?S PRIOR AUTHORIZATION REQUIRED For purposes other than those mentioned above, we are required to ask for our patients? written authorizations before using or disclosing any of their PHI. If we request an authorization, any of our patients may decline to agree, and if a patient gives us an authorization, the patient has the right to revoke the authorization and by doing so, stop any future uses and disclosures of the patient?s health information that the authorization covered. An example of a situation where the patient?s prior authorization would be required would be if we wish to conduct a marketing program that would involve the use of PHI. 2. PATIENTS? RIGHTS HIPAA and the Regulations provide our patients with rights concerning their PHI. With limited exceptions (which are subject to review) each patient has the right to the following: (a) Patient?s Record. Each patient can obtain a copy of his or her PHI by completing our request form. The only charge will be based on our cost in responding to the request. The amount of the charge will vary depending on the format the patient requests and whether the patient wants the record or a summary, and whether it is to be delivered by mail or otherwise. The patient will be told of the fee when the patient?s request is received. (b) Accounting for Disclosures. By completing our request form, each patient is entitled to obtain a list of the disclosures of the patient?s PHI that have occurred within a period of 6 years after April 14, 2003, except for disclosures made for the purposes of treatment, payment or health care operations and certain others. There will be no charge for the first request in any 12 month period, but we are entitled to charge a reasonable cost based fee for additional request made in the same time period of time. (c) Amendments. Each patient may ask to change the record of his or her own PHI by completing our request form explaining why the change should be made. WE will review the request, but may decline to make the change if in our professional judgment we conclude that the record should not be changed. (d) Communications. By completing our request form, each patient can ask us to communicate with him or her about their own PHI in a confidential manner such as by sending mail to an address other than the home address or using a particular telephone number. (e) Special Restrictions. By completing our request form, each pateitn can ask us to adopt special restrictions that further limit our use and disclosure of the patient?s PHI (except where use and disclosure are required of us by law or in emergency circumstances). We will consider the request; but in accordance with HIPAA and the Regulations, we are not required to agree with the request. (f) Complaints. If a patient believes that we have violated the patient?s rights as to the patient?s PHI under HIPAA and the Regulations, or if a patient disagrees with a decision we made about access to the patient?s PHI, the patient has the right to complete our complaint form and deliver it to our Contact Person listed below. Our Contact Person is required to investigate, and if possible, to resolve each such complaint, and to advise the patient accordingly. The patient also has the right to send a written complaint to the U.S. Department of Health and Human Services. Under no circumstances will any patient be retaliated against by this Pharmacy for filing a complaint. We are required by law to protect the privacy of our patients? PHI, to provide this notice about our practices, and follow the privacy practices that are described in this notice. We reserve the right to make changes in our privacy practices that will apply to the entire PHI we maintain. A new notice will be available on request before any significant change is made.
       
       
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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

    Store Location & Directions

    6th SOUTH MAIN
    Grace, ID, 83241
    (208) 425-3766

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    Pharmacy Hours

    Mon - Sat: 9:00am - 6:00pm;Sun:Closed;

    Store Hours

    Mon - Sat: 9:00am - 6:00pm;Sun:Closed;
     
     
     
    • HIPAA
      Notice of Privacy
    • About HIPAA’s Notice of Privacy and how it protects you.

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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.