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HIPAA Notice of Privacy Practice
FORM D-1: Notice of Privacy Practices
Robert W. Curlis, R. Ph.
d/b/a Sidney Hometown Pharmacy
130 West Russell Road
Sidney, Oh 45365

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.
Our Pledge To You. Your health information -- which means any written or oral information that we create or receive that describes your health condition, treatment or payments -- is personal. Therefore, the Pharmacy pledges to protect your health information as required by law. We give you this Privacy Notice to tell you (1) how we will use and disclose your “protected” health information, or “PHI” and (2) how you can exercise certain individual rights related to your PHI as a Patient of Sidney Hometown Pharmacy. Please note that if any of your PHI qualifies as mental health records, alcohol and drug treatment records, communicable disease records or genetic test records, we will safeguard these records as “Special PHI” which will be disclosed only with your prior express written authorization, pursuant to a valid court order or as otherwise required by law. We are required by law to maintain the privacy of your PHI and to provide you with this notice of our legal duties and privacy practices.
I. How We Will Use And Disclose Your PHI
A. To Provide Treatment. We may use and disclose your PHI to provide, coordinate, or manage your treatment, medications and services you received from the Pharmacy. For example, we may contact you regarding medications, equipment, supplies, compliance programs such as drug recommendations, therapeutic substitutions, refill reminders or other products or service recommendations, such as specialty and infusion therapies, counseling and drug utilization review (DUR), product recalls or disease statement management.
B. To Obtain Payment. We may also use and disclose your PHI, as needed, to obtain payment for services that we provide to you. This may include certain communications to your health insurer, a pharmacy benefit manager, health plan, or other health care payor, to confirm (1) your eligibility for health benefits, (2) the medical necessity of a particular service or procedure, or (3) any prior authorization or utilization review requirements. We will bill your third party payer for the cost of medications, equipment and supplies dispensed to you. The information on or accompanying the bill may include information that identifies you as well as the medications you are taking. We may also disclose your PHI to another provider involved in your care for the other provider's payment activities. For example, this may include disclosure of demographic information to another physician practice that is involved in your care, or to a hospital where you were recently hospitalized, for payment purposes.
C. To Perform Health Care Operations. We may also use or disclose your PHI, as necessary, to carry on our day-to-day health care operations, and to provide quality care to all of our Patients, but only on a "need to know" basis. These health care operations may include such activities as: quality improvement; physician and employee reviews; health professional training programs, including those in which students, trainees, or practitioners in health care learn under supervision; accreditation; certification; licensing or credentialing activities; compliance reviews and audits; defending a legal or administrative claim; business management development; and other administrative activities. In certain situations, we may also disclose your PHI to another health care provider or health plan to conduct their own particular health care operation requirements.
D. To Contact You. To support our treatment, payment and health care operations, we may also contact you at home, either by telephone or mail, from time to time (1) to remind you of prescription fills and refills, or an upcoming appointment date or (2) to ask you to return a call to the Pharmacy unless you ask us, in writing, to use alternative means to communicate with you regarding these matters. We may also contact you by telephone to inform you of specific test results or treatment plans, but only with your prior written authorization.
E. To Be In Contact With Your Family or Friends. Additionally, we may also disclose certain of your PHI to your family members or other relatives, a close personal friend, or any other person specified by you from time to time, but only if the PHI is directly related (1) to the person's involvement in your treatment or related payments, or (2) to notify the person of your physical location or a sudden change in your condition, while receiving treatment at our office. Although you have a right to request reasonable restrictions on these disclosures, we will only be able to grant those restrictions that are reasonable and not too difficult to administer, none of which would apply in the case of an emergency.
F. To Conduct Research. Under certain circumstances, we may use and disclose certain of your PHI for research purposes, but only if the research is subject to special approval procedures and the necessary rules governing uses and disclosures are agreed to by the researchers. For example, a research project may compare two different medications used to treat a particular condition in two different groups of Patients by comparing the Patients' health and recovery in one group with the second group. Any other research will require your written authorization.
G. According to Laws That Require or Permit Disclosure. We may disclose your PHI when we are required or permitted to do so by any federal, state or local law, as follows:
1. When There Are Risks to Public Health. We may disclose your PHI to (1) report disease, injury or disability; (2) report vital events such as births and deaths; (3) conduct public health activities; (4) collect and track FDA-related events and defects; (5) notify appropriate persons regarding communicable disease concerns; or (6) inform employers about particular workforce issues.
2. To Report Suspected Abuse, Neglect Or Domestic Violence. We may notify government authorities if we believe that a Patient is the victim of abuse, neglect or domestic violence, but only when specifically required or authorized by law or when the Patient agrees to the disclosure.
3. To Conduct Health Oversight Activities. We may disclose your PHI to a health oversight agency for activities including audits; civil, administrative, or criminal investigations, proceedings, or actions; inspections; licensure or disciplinary actions; or other activities necessary for appropriate oversight, but we will not disclose your PHI if you are the subject of an investigation and your PHI is not directly related to your receipt of health care or public benefits.
4. In Connection With Judicial and Administrative Proceedings. We may disclose your PHI in the course of any judicial or administrative proceeding in response to an order of a court or administrative tribunal. In certain circumstances, we may disclose your PHI in response to a subpoena if we receive satisfactory assurances that you have been notified of the request or that an effort was made to secure a protective order.
5. For Law Enforcement Purposes. We may disclose your PHI to a law enforcement official to, among other things, (1) report certain types of wounds or physical injuries, (2) identify or locate certain individuals, (3) report limited information if you are the victim of a crime or if your health care was the result of criminal activity, but only to the extent required or permitted by law.
6. To Coroners, Funeral Directors, and for Organ Donation. We may disclose PHI to a coroner or medical examiner for identification purposes, to determine cause of death or for the coroner or medical examiner to perform other duties. We may also disclose PHI to a funeral director in order to permit the funeral director to carry out their duties. PHI may also be disclosed for organ, eye or tissue donation purposes.
7. In the Event of a Serious Threat to Health or Safety, or For Specific Government Functions. We may, consistent with applicable law and ethical standards of conduct, use or disclose your PHI if we believe, in good faith, that such use or disclosure is necessary to prevent or lessen a serious and imminent threat to your health or safety or to the health and safety of the public, or for certain other specified government functions permitted by law.
8. For Worker’s Compensation. We may disclose your PHI to comply with worker‘s compensation laws or similar programs.
9. To Conduct Fundraising. Under certain circumstances, we may use and disclose certain of your PHI to communicate with you and conduct fundraising activities on our behalf, but only when permitted by HIPAA. Please note that you always have the right to "opt out" of receiving any future fundraising communications and any such decision will have no impact on your treatment or payment for services.
10. To Communicate With You Regarding Your Treatment. We may also communicate information to you, from time to time, that may encourage you to use or purchase a particular product or service, but only as it relates to your treatment and only when permitted by HIPAA.
H. With Your Prior Express Written Authorization. Other than as stated above, we will not disclose your PHI, or more importantly, your Special PHI, without first obtaining your express written authorization. We will not use or disclose your PHI in any of the following situations without your written authorization:
1. Uses and disclosures of Special PHI (if recorded by us in the medical record) except to carry out your treatment, payment or health care operations, to the extent permitted or required by law;
2. Uses and disclosures of PHI to conduct certain marketing activities that may encourage you to use or purchase a particular product or service for which HIPAA requires your prior express written authorization;
3. Disclosures of PHI that constitutes a sale of your PHI under HIPAA;
4. Uses and disclosures of certain PHI for fundraising purposes that are not otherwise permitted by HIPAA;
5. Psychotherapy notes; and
6. Other uses and disclosures not described in this Notice.
II. Your Individual Rights Concerning Your PHI

A. The Right to Request Restrictions on How We Use and Disclose Your PHI. You may ask us not to use or disclose certain parts of your PHI but only if the request is reasonable. For example, if you pay for a particular service in full, out-of-pocket, on the date of service, you may ask us not to disclose any related PHI to your health plan. You may also ask us not to disclose your PHI to certain family members or friends who may be involved in your care or for other notification purposes described in this Privacy Notice, or how you would us to communicate with you regarding upcoming appointments, treatment alternatives and the like by contacting you at a telephone number or address other than at home. Please note that we are only required to agree to those restrictions that are reasonable and which are not too difficult for us to administer. We will notify you if we deny any part of your request, but if we are able to agree to a particular restriction, we will communicate and comply with your request, except in the case of an emergency. Under certain circumstances, we may choose to terminate our agreement to a restriction if it becomes too burdensome to carry out. Finally, please note that it is your obligation to notify us if you wish to change or update these restrictions after your visit by contacting the Privacy Officer directly.
B. The Right to Opt Out of Fundraising. We may use or disclose your name, address, telephone number or e-mail information, age, date of birth, gender, health insurance status, dates of service, department of service information, treating physician information or outcome information, to a Business Associate or institutionally related foundation, for the purpose of raising money for the Pharmacy’s benefit. Although we may contact you to raise funds for the Pharmacy, you have the right to opt out of receiving future fundraising communications, and your decision will have no impact on your treatment or payment for services at the Pharmacy.
C. The Right to Receive Confidential Communications of PHI. You may request to receive communications of PHI from us by alternative means or at alternative locations, and we will work with you to reasonably accommodate your request. For example, if you prefer to receive communications of PHI from us only at a certain address, phone number or other method, you may request such a method.
D. The Right to Inspect and Copy Your PHI. You may inspect and obtain a copy of your PHI that we have created or received as we provide your treatment or obtain payment for your treatment. A copy may be made available to you either in paper or electronic format if we use an electronic health format. Under federal law, however, you may not inspect or copy the following records: psychotherapy notes; information compiled in reasonable anticipation of, or for use in, a civil, criminal, or administrative action or proceeding; and PHI that is subject to a law prohibiting access. Depending on the circumstances, you may have the right to request a second review if our Privacy Officer denies your request to access your PHI. Please note that you may not inspect or copy your PHI if your physician believes that the access requested is likely to endanger your life or safety or that of another person, or if it is likely to cause substantial harm to another person referenced within the information. As before, you have the right to request a second review of this decision. To inspect and copy your PHI, you must submit a written request to the Privacy Officer. We may charge you a fee for the reasonable costs that we incur in processing your request.
E. The Right to Request Amendments To Your PHI. You may request that your PHI be amended so long as it is a part of our official Patient Record. All such requests must be in writing and directed to our Privacy Officer. 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 us and we may respond to your statement in writing and provide you with a copy.
F. The Right to Receive an Accounting of Disclosures of PHI. You have the right to request an accounting of those disclosures of your PHI that we have made for reasons other than those for treatment, payment and health care operations, which are specified in Section II (A-C) above. The accounting is not required to report PHI disclosures (1) to those family, friends and other persons involved in your treatment or payment, (2) that you otherwise requested in writing, (3) that you agreed to by signing an authorization form, or (4) that we are otherwise required or permitted to make by law. As before, your request must be made in writing to our Privacy Officer. The request should specify the time period, but please note that we are not required to provide an accounting for disclosures that take place prior to April 14, 2003. Accounting requests may not be made for periods of time in excess of six years. We will provide the first accounting you request during any 12-month period without charge. Subsequent accounting requests may be subject to a reasonable cost-based fee.
G. The Right to Receive Notice of a Breach. You have the right to receive written notice in the event we learn of any unauthorized acquisition, use or disclosure of your PHI that was not otherwise properly secured as required by HIPAA. We will notify you of the breach as soon as possible but no later than sixty (60) days after the breach has been discovered.
H. The Right to File A Complaint. You have the right to contact our Privacy Officer at any time if you have questions, comments or complaints about our privacy practices or if you believe we have violated your privacy rights. You also have the right to contact our Privacy Officer or the Department of Health and Human Services’ Office for Civil Rights in Baltimore, Maryland regarding these privacy matters, particularly if you do not believe that we have been responsive to your concerns. We urge you to contact our Privacy Officer if you have any questions, comments or complaints, either in writing or by telephone. Please note that we will not take any action, or otherwise retaliate, against you in any way as a result of your communications to the Pharmacy or to the Department of Health and Human Services’ Office for Civil Rights. As always, please feel free contact us. We look forward to serving you as a Patient.
I. Your Right to Revoke Authorization. Any other uses and disclosures not described in this Notice will be made only with your written authorization. Please note that you may revoke your authorization in writing at any time except to the extent that we have taken action in reliance upon the authorization.

About Us

A good neighbor is someone who cares about your community, your family, and your wellbeing. That’s Sidney Hometown Pharmacy, your local Good Neighbor Pharmacy. Sidney Hometown Pharmacy has been part of the local community since 1996, serving the residents of Sidney and surrounding area. As a member of Good Neighbor Pharmacy, we’re able to offer quality products and services – at prices that are competitive with the big national chains. Plus, we offer a special dose of caring that makes you feel right at home. Get to know us, and get to know the value we can bring to your family’s life.

    HIPAA Notice of Privacy Practice
    FORM D-1: Notice of Privacy Practices
    Robert W. Curlis, R. Ph.
    d/b/a Sidney Hometown Pharmacy
    130 West Russell Road
    Sidney, Oh 45365

    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.
    Our Pledge To You. Your health information -- which means any written or oral information that we create or receive that describes your health condition, treatment or payments -- is personal. Therefore, the Pharmacy pledges to protect your health information as required by law. We give you this Privacy Notice to tell you (1) how we will use and disclose your “protected” health information, or “PHI” and (2) how you can exercise certain individual rights related to your PHI as a Patient of Sidney Hometown Pharmacy. Please note that if any of your PHI qualifies as mental health records, alcohol and drug treatment records, communicable disease records or genetic test records, we will safeguard these records as “Special PHI” which will be disclosed only with your prior express written authorization, pursuant to a valid court order or as otherwise required by law. We are required by law to maintain the privacy of your PHI and to provide you with this notice of our legal duties and privacy practices.
    I. How We Will Use And Disclose Your PHI
    A. To Provide Treatment. We may use and disclose your PHI to provide, coordinate, or manage your treatment, medications and services you received from the Pharmacy. For example, we may contact you regarding medications, equipment, supplies, compliance programs such as drug recommendations, therapeutic substitutions, refill reminders or other products or service recommendations, such as specialty and infusion therapies, counseling and drug utilization review (DUR), product recalls or disease statement management.
    B. To Obtain Payment. We may also use and disclose your PHI, as needed, to obtain payment for services that we provide to you. This may include certain communications to your health insurer, a pharmacy benefit manager, health plan, or other health care payor, to confirm (1) your eligibility for health benefits, (2) the medical necessity of a particular service or procedure, or (3) any prior authorization or utilization review requirements. We will bill your third party payer for the cost of medications, equipment and supplies dispensed to you. The information on or accompanying the bill may include information that identifies you as well as the medications you are taking. We may also disclose your PHI to another provider involved in your care for the other provider's payment activities. For example, this may include disclosure of demographic information to another physician practice that is involved in your care, or to a hospital where you were recently hospitalized, for payment purposes.
    C. To Perform Health Care Operations. We may also use or disclose your PHI, as necessary, to carry on our day-to-day health care operations, and to provide quality care to all of our Patients, but only on a "need to know" basis. These health care operations may include such activities as: quality improvement; physician and employee reviews; health professional training programs, including those in which students, trainees, or practitioners in health care learn under supervision; accreditation; certification; licensing or credentialing activities; compliance reviews and audits; defending a legal or administrative claim; business management development; and other administrative activities. In certain situations, we may also disclose your PHI to another health care provider or health plan to conduct their own particular health care operation requirements.
    D. To Contact You. To support our treatment, payment and health care operations, we may also contact you at home, either by telephone or mail, from time to time (1) to remind you of prescription fills and refills, or an upcoming appointment date or (2) to ask you to return a call to the Pharmacy unless you ask us, in writing, to use alternative means to communicate with you regarding these matters. We may also contact you by telephone to inform you of specific test results or treatment plans, but only with your prior written authorization.
    E. To Be In Contact With Your Family or Friends. Additionally, we may also disclose certain of your PHI to your family members or other relatives, a close personal friend, or any other person specified by you from time to time, but only if the PHI is directly related (1) to the person's involvement in your treatment or related payments, or (2) to notify the person of your physical location or a sudden change in your condition, while receiving treatment at our office. Although you have a right to request reasonable restrictions on these disclosures, we will only be able to grant those restrictions that are reasonable and not too difficult to administer, none of which would apply in the case of an emergency.
    F. To Conduct Research. Under certain circumstances, we may use and disclose certain of your PHI for research purposes, but only if the research is subject to special approval procedures and the necessary rules governing uses and disclosures are agreed to by the researchers. For example, a research project may compare two different medications used to treat a particular condition in two different groups of Patients by comparing the Patients' health and recovery in one group with the second group. Any other research will require your written authorization.
    G. According to Laws That Require or Permit Disclosure. We may disclose your PHI when we are required or permitted to do so by any federal, state or local law, as follows:
    1. When There Are Risks to Public Health. We may disclose your PHI to (1) report disease, injury or disability; (2) report vital events such as births and deaths; (3) conduct public health activities; (4) collect and track FDA-related events and defects; (5) notify appropriate persons regarding communicable disease concerns; or (6) inform employers about particular workforce issues.
    2. To Report Suspected Abuse, Neglect Or Domestic Violence. We may notify government authorities if we believe that a Patient is the victim of abuse, neglect or domestic violence, but only when specifically required or authorized by law or when the Patient agrees to the disclosure.
    3. To Conduct Health Oversight Activities. We may disclose your PHI to a health oversight agency for activities including audits; civil, administrative, or criminal investigations, proceedings, or actions; inspections; licensure or disciplinary actions; or other activities necessary for appropriate oversight, but we will not disclose your PHI if you are the subject of an investigation and your PHI is not directly related to your receipt of health care or public benefits.
    4. In Connection With Judicial and Administrative Proceedings. We may disclose your PHI in the course of any judicial or administrative proceeding in response to an order of a court or administrative tribunal. In certain circumstances, we may disclose your PHI in response to a subpoena if we receive satisfactory assurances that you have been notified of the request or that an effort was made to secure a protective order.
    5. For Law Enforcement Purposes. We may disclose your PHI to a law enforcement official to, among other things, (1) report certain types of wounds or physical injuries, (2) identify or locate certain individuals, (3) report limited information if you are the victim of a crime or if your health care was the result of criminal activity, but only to the extent required or permitted by law.
    6. To Coroners, Funeral Directors, and for Organ Donation. We may disclose PHI to a coroner or medical examiner for identification purposes, to determine cause of death or for the coroner or medical examiner to perform other duties. We may also disclose PHI to a funeral director in order to permit the funeral director to carry out their duties. PHI may also be disclosed for organ, eye or tissue donation purposes.
    7. In the Event of a Serious Threat to Health or Safety, or For Specific Government Functions. We may, consistent with applicable law and ethical standards of conduct, use or disclose your PHI if we believe, in good faith, that such use or disclosure is necessary to prevent or lessen a serious and imminent threat to your health or safety or to the health and safety of the public, or for certain other specified government functions permitted by law.
    8. For Worker’s Compensation. We may disclose your PHI to comply with worker‘s compensation laws or similar programs.
    9. To Conduct Fundraising. Under certain circumstances, we may use and disclose certain of your PHI to communicate with you and conduct fundraising activities on our behalf, but only when permitted by HIPAA. Please note that you always have the right to "opt out" of receiving any future fundraising communications and any such decision will have no impact on your treatment or payment for services.
    10. To Communicate With You Regarding Your Treatment. We may also communicate information to you, from time to time, that may encourage you to use or purchase a particular product or service, but only as it relates to your treatment and only when permitted by HIPAA.
    H. With Your Prior Express Written Authorization. Other than as stated above, we will not disclose your PHI, or more importantly, your Special PHI, without first obtaining your express written authorization. We will not use or disclose your PHI in any of the following situations without your written authorization:
    1. Uses and disclosures of Special PHI (if recorded by us in the medical record) except to carry out your treatment, payment or health care operations, to the extent permitted or required by law;
    2. Uses and disclosures of PHI to conduct certain marketing activities that may encourage you to use or purchase a particular product or service for which HIPAA requires your prior express written authorization;
    3. Disclosures of PHI that constitutes a sale of your PHI under HIPAA;
    4. Uses and disclosures of certain PHI for fundraising purposes that are not otherwise permitted by HIPAA;
    5. Psychotherapy notes; and
    6. Other uses and disclosures not described in this Notice.
    II. Your Individual Rights Concerning Your PHI

    A. The Right to Request Restrictions on How We Use and Disclose Your PHI. You may ask us not to use or disclose certain parts of your PHI but only if the request is reasonable. For example, if you pay for a particular service in full, out-of-pocket, on the date of service, you may ask us not to disclose any related PHI to your health plan. You may also ask us not to disclose your PHI to certain family members or friends who may be involved in your care or for other notification purposes described in this Privacy Notice, or how you would us to communicate with you regarding upcoming appointments, treatment alternatives and the like by contacting you at a telephone number or address other than at home. Please note that we are only required to agree to those restrictions that are reasonable and which are not too difficult for us to administer. We will notify you if we deny any part of your request, but if we are able to agree to a particular restriction, we will communicate and comply with your request, except in the case of an emergency. Under certain circumstances, we may choose to terminate our agreement to a restriction if it becomes too burdensome to carry out. Finally, please note that it is your obligation to notify us if you wish to change or update these restrictions after your visit by contacting the Privacy Officer directly.
    B. The Right to Opt Out of Fundraising. We may use or disclose your name, address, telephone number or e-mail information, age, date of birth, gender, health insurance status, dates of service, department of service information, treating physician information or outcome information, to a Business Associate or institutionally related foundation, for the purpose of raising money for the Pharmacy’s benefit. Although we may contact you to raise funds for the Pharmacy, you have the right to opt out of receiving future fundraising communications, and your decision will have no impact on your treatment or payment for services at the Pharmacy.
    C. The Right to Receive Confidential Communications of PHI. You may request to receive communications of PHI from us by alternative means or at alternative locations, and we will work with you to reasonably accommodate your request. For example, if you prefer to receive communications of PHI from us only at a certain address, phone number or other method, you may request such a method.
    D. The Right to Inspect and Copy Your PHI. You may inspect and obtain a copy of your PHI that we have created or received as we provide your treatment or obtain payment for your treatment. A copy may be made available to you either in paper or electronic format if we use an electronic health format. Under federal law, however, you may not inspect or copy the following records: psychotherapy notes; information compiled in reasonable anticipation of, or for use in, a civil, criminal, or administrative action or proceeding; and PHI that is subject to a law prohibiting access. Depending on the circumstances, you may have the right to request a second review if our Privacy Officer denies your request to access your PHI. Please note that you may not inspect or copy your PHI if your physician believes that the access requested is likely to endanger your life or safety or that of another person, or if it is likely to cause substantial harm to another person referenced within the information. As before, you have the right to request a second review of this decision. To inspect and copy your PHI, you must submit a written request to the Privacy Officer. We may charge you a fee for the reasonable costs that we incur in processing your request.
    E. The Right to Request Amendments To Your PHI. You may request that your PHI be amended so long as it is a part of our official Patient Record. All such requests must be in writing and directed to our Privacy Officer. 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 us and we may respond to your statement in writing and provide you with a copy.
    F. The Right to Receive an Accounting of Disclosures of PHI. You have the right to request an accounting of those disclosures of your PHI that we have made for reasons other than those for treatment, payment and health care operations, which are specified in Section II (A-C) above. The accounting is not required to report PHI disclosures (1) to those family, friends and other persons involved in your treatment or payment, (2) that you otherwise requested in writing, (3) that you agreed to by signing an authorization form, or (4) that we are otherwise required or permitted to make by law. As before, your request must be made in writing to our Privacy Officer. The request should specify the time period, but please note that we are not required to provide an accounting for disclosures that take place prior to April 14, 2003. Accounting requests may not be made for periods of time in excess of six years. We will provide the first accounting you request during any 12-month period without charge. Subsequent accounting requests may be subject to a reasonable cost-based fee.
    G. The Right to Receive Notice of a Breach. You have the right to receive written notice in the event we learn of any unauthorized acquisition, use or disclosure of your PHI that was not otherwise properly secured as required by HIPAA. We will notify you of the breach as soon as possible but no later than sixty (60) days after the breach has been discovered.
    H. The Right to File A Complaint. You have the right to contact our Privacy Officer at any time if you have questions, comments or complaints about our privacy practices or if you believe we have violated your privacy rights. You also have the right to contact our Privacy Officer or the Department of Health and Human Services’ Office for Civil Rights in Baltimore, Maryland regarding these privacy matters, particularly if you do not believe that we have been responsive to your concerns. We urge you to contact our Privacy Officer if you have any questions, comments or complaints, either in writing or by telephone. Please note that we will not take any action, or otherwise retaliate, against you in any way as a result of your communications to the Pharmacy or to the Department of Health and Human Services’ Office for Civil Rights. As always, please feel free contact us. We look forward to serving you as a Patient.
    I. Your Right to Revoke Authorization. Any other uses and disclosures not described in this Notice will be made only with your written authorization. Please note that you may revoke your authorization in writing at any time except to the extent that we have taken action in reliance upon the authorization.
       
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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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    130 West Russell Road
    Sidney, OH, 45365-1754
    (937) 498-4846

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    Pharmacy Hours

    Mon-Fri 9:30am - 6:00pm;Sat: 9:00am - 1:00pm;Sun: Closed;

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