PATIENT INFORMATION:

NAME: ________________________________________________

ADDRESS: _____________________________________________

CITY,STATE,ZIP_________________________________________

DAYTIME PHONE:_______________________________________

DATE OF BIRTH:_________________________________________

DRUG ALLERGIES:_______________________________________

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.

This notice of Privacy practices (NOP) describes how we may use and disclose PHI about you to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law. It also describes your rights to access and control PHI about you. “PHI” is information about you, including demographic 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.

I acknowledge receipt of Pavilion Compounding Pharmacy’s Notice of Privacy Practices

Patient Signature__________________________________________________

Date:_________________________

Signature of parent of minor patient___________________________________

Definitions

1. “Designated Record Set,” means a group of records maintained by or for us that is used, in whole or in part, by or for us to make decisions about Patients. Our Designated Record Set includes, prescriptions, record of payment, claims adjudication, and patient medical records and billing records maintained by us.
2. “Disclose,” means the release, transfer or provision of access to PHI, whether oral or recorded in any form or medium.
3. “Identifying Characteristic” includes all of the following as well as any other unique information: name; address; name of employers; all elements of dates, including birth date, injury date, etc.; telephone numbers; fax numbers; mail address; social security number; health plan beneficiary number.
4. “Individually Identifiable” means information that contains any identifying characteristic.
5. “Patient” means any individual that receives healthcare services from us.
6. “Protected Health Information” means any information, whether oral or recorded in any form or medium, that relates to the past, present or future physical or mental health or condition of a Patient the provision of health care to a Patient, or the past, present or future payment for the provision of health care to Patient, consistent with 45 CFR §- 164.501.
7. “Use” means, with respect to individually identifiable health information, the sharing, employment, application, utilization, examination, or analysis of such information within an entity that maintains such information.
8. “Other Terms”. Capitalized terms (not all caps) contained herein but not otherwise defined shall have the meaning given to such terms in 45 CFR § 160.103 and 164.501.

Our Responsibilities

We are required to:

• Maintain the privacy of your health information in accordance with the our Privacy Policies and Procedures and in accordance with applicable federal and state law;
• Provide you with this NOP as to our legal duties and privacy practices and your rights with respect to information we collect and maintain about you;
• Abide by the terms of this NOP;
• Accommodate reasonable requests you may have to communicate health information by alternative means or at alternative locations; and
• Notify you if we are unable to agree to a requested restriction.
• We will promptly revise and post this NOP whenever there is a material change to the uses of disclosures, your rights in PHI about you, our rights, our legal duties or other privacy practices stated in this NOP. We may change the terms of our NOP at any time. We reserve the right to make any changes in our privacy practice effective for all PHI maintained by us. We will make our NOP available upon request on or after the effective date of the revision. Upon your request, we will provide you with a copy of our NOP. A coy of this Notice will also be posted in a clear and prominent location in our pharmacy.

Uses and Disclosures of PHI

PHI about you may be used and disclosed by us, pharmacy staff and others outside of our office that are involved in the provision of and payment for health care services provided to you.

The following are examples of the types of uses and disclosures of PHI about you. These examples are not meant to be exhaustive, but to describe the types of uses and disclosures that may be made by our office.

Treatment. We will use and disclose PHI about you to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with your physician or other third party involved in your care. For example, we may disclose PHI about you to other physicians treating you to ensure they have the necessary information to diagnose or treat you.

Payment. PHI about you will be used, as needed, to facilitate and coordinate payment for your health care services. This may include certain activities that your health plan may undertake before it approves or pays for you health care services such as; making a determination of eligibility or coverage for insurance benefits, reviewing services provided to you for medical necessity, and undertaking utilization review activities.

Health Care Operations. We may use or disclose, as needed, PHI about you in order to support our health care operations. For example, we may use information about you to assess the quality of the services provided by us. We may also ask you to sign for your prescriptions and may also call you by your name when your prescriptions are ready. We may use PHI about you, as necessary, to contact you to remind you of your refills or let you know your prescription is ready.

Business Associates. We will share PHI about you with third party “business associates” that perform various activities (e.g., legal services, computer services, claims transmittal) for us. Whenever an arrangement between a business associate and us involves the use or disclosure of PHI about you, we will have a written contract that contains terms that will protect the privacy of PHI about you.

Treatment Alternatives and Other Services. We may use or disclose PHI about you, as necessary, to provide you with information about treatment alternatives or other health-related benefits and services that may be of interest to you. For example, your name and address may be used to send you a newsletter about us and the services we offer. You may contact our Privacy Officer to request that these materials not be sent to you.

Other Uses and Disclosures of PHI about You.

Uses and disclosures of PHI about you other than for treatment, payment and health care operations will be made only with your written authorization, unless otherwise permitted or required by law as described below. You may revoke this authorization, at any time, by providing written notice of the revocation to our Privacy Officer. We will honor your revocation once we receive it, but we cannot honor a revocation retroactively.

Disclosure of PHI to Legal Guardians, Family Members, Friends and Others Involved in Patient’s Care: Unless a Patient objects or requests additional privacy restrictions or alternative communications that are accepted by us we may, in the exercise of professional judgment, disclose to a patient’s legal guardian, family member, other relative, or close personal friend, PHI directly relevant to such person’s involvement with the Patient’s care or payment related to such care. We may reasonably infer from the circumstances surrounding the request, or otherwise utilize our professional judgment and experience with common practice to make reasonable inferences of the patient’s best interest in disclosing PHI to an individual on behalf of a patient. For example, we may release your filled prescription to another family member or friend you have requested to pick up your prescription.

Permitted and Required Uses and Disclosures That may Be Made Without Your Authorization or Opportunity to Object: We may use of disclose PHI about you in the following situations without your consent or authorization. These situations include:

Required by Law: We may use or disclose PHI about you to the extent that the use or disclosure is required by law. The use or disclosure will be make in compliance with the law and will be limited to the relevant requirements of the law. You will be notified, to the extent required by law, of any such uses or disclosures.

Public Health: We may disclose PHI about you for public health activities and purposes to a public health authority that is permitted by law to collect or receive the information. The disclosure will be made for the purpose of controlling disease, injury or disability. We may also disclose PHI about you, if directed by the public health authority, to a foreign government agency that is collaborating with the public health authority.

Communicable Diseases: We may disclose PHI about you, if authorized by law, to a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading the disease or condition.

Health Oversight: We may disclose PHI to a health oversight agency for activities authorized by law, such as audits, investigations and inspections. Oversight agencies seeking the information include government agencies that oversee the health care system, government benefit programs, other government regulatory programs and civil rights laws.

Food and Drug Administration: We may disclose PHI about you to a person or company required by the Food and Drug Administration to: (i) report adverse events, product defects or problems, biologic product deviations, (ii) track products, (iii) enable product recalls; (iv) make repairs or replacements; or (v) conduct post marketing surveillance, as required.

Legal Proceedings: In accordance with applicable federal and state law, we may disclose PHI in the course of any judicial or administrative proceeding, in response to an order of a court or administrative tribunal (to the extent such disclosure is expressly authorized), in certain conditions in response to a subpoena, discovery request or other lawful process.

Law Enforcement: In accordance with applicable law, we may also disclose PHI for law enforcement purposes. These law enforcement purposes include: (1) legal processes; (2) limited information requests for identification and location purposes pertaining to a crime, the perpetration of a crime or victims of a crime; (3) information requests stemming from suspicion that death has occurred as a result of criminal conduct; and (4) information requests related to a crime that occurred on our premises.

National Security: We may release PHI about you to authorized federal officials for intelligence, special investigations, counterintelligence and other national security activities authorized by law, and for the protection of the President, other authorized person or foreign heads of state.

Coroners, Funeral Directors, and Organ Donation: We may disclose PHI to a coroner or medical examiner for identification purposes, determining cause of death or for the coroner or medical examiner to perform other duties authorized by law. We may also disclose PHI to a funeral director, as authorized by law, in order to permit the funeral director to carry out his/her duties. We may disclose such information in reasonable anticipation of death. PHI may be used and disclosed for cadaver organ, eye or tissue donation purposes.

Criminal Activity: Consistent with applicable federal and state laws, we may disclose PHI about you, if we believe that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. We may also disclose PHI if it is necessary for law enforcement authorities to identify or apprehend an individual.

Military Activity and National Security: When the appropriate conditions apply, we may use or disclose PHI of Patients who are Armed Forces personnel: (1) for activities deemed necessary by appropriate military command authorities; (2) for the purpose of a determination by the Department of Veterans Affairs of your eligibility for the benefits; or (3) to foreign military authority if you are a Patient of that foreign military services. We may also disclose PHI about you to authorized federal officials for conducting national security and intelligence activities, including for the provision of protective services to the President or others legally authorized.

Workers’ Compensation: We may disclose PHI about you as authorized to comply with workers’ compensation laws and other similar programs.

Inmates: We may use or disclose PHI about you if you are an inmate of a correctional facility in the course of providing care to you or for the health and safety of others.

Required Uses and Disclosures: Under the law, we must make disclosures of PHI about you when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirement of Section 164.500 et seq.

Your Rights

Following is a statement of your rights with respect to PHI about you and a brief description of how you may exercise these rights.

Right to Inspect and Copy. You have the right to inspect and obtain a copy of medical information that may be maintained by us. Usually, this includes prescription and billing records, but does not include psychotherapy notes.

Under federal law, however, you may not inspect or obtain a copy of the following records: psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding; and protected health information that is subject to law that prohibits access to protected health information.

To inspect and obtain a copy of PHI, about you, you must make a request in writing to our Privacy Officer.

The requested information will be provided within thirty (30) days if the information is maintained on site or within sixty (60) days if the information is maintained off site. We may ask for a single thirty (30) day extension to those deadlines.

We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to medical information, we will provide you with a written denial setting forth the basis of the denial, a description of how you may exercise your review rights and a description of how you may file a complaint.

Right to Amend. If you feel that medical information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as we keep the information.

We have sixty (60) days after receiving your written ammendment request to act on this request. We are entitled to a single thirty (30) day extension in the event we are unable to comply with the deadline.

We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that:

• Was not created by us, unless the person or entity that created the information is no longer available to make the amendment;
• Is not part of the medical information kept by or for us;
• Is not part of the information which you would be permitted to inspect and copy; or
• Is accurate and complete.

If your request is denied in whole or in part, we will provide you with a written denial that explains the basis of the denial. You may submit a written statement disagreeing with the denial and you may require just to include the statement, or if no statement if filed, a copy of your Amendment Request and our written denial with any future disclosures of the PHI.

Right to an Accounting of Disclosures: You have the right to request an accounting of disclosures. An “accounting of disclosures” is a list of certain disclosures of PHI about you that we have made to others. The accounting will exclude certain disclosures, such as disclosures made directly to you, disclosures you authorize, disclosures to friends or family members involved in your care and disclosures for notification purposes.

To request an accounting of disclosure, you must submit a request in writing to our Privacy Officer. Your request must state a time period, which may not be longer than six (6) years and may not include dates before April 14, 2003.

We will attempt to comply with your Accounting of Disclosures Request within sixty (60) days. We will be permitted an additional thirty (30) days to comply with the request as long as we provide you with a written statement detailing the reasons for the delay and the date by which the accounting will be provided.

Right to request Restrictions. You have the right to request a restriction or limitations on the medical information we use or disclose about you for treatment, payment or health care operations. You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend. For example, you could ask that we not disclose information to your spouse.

To request further restrictions on the use of disclosure of PHI about you, you must submit in writing the request to our Privacy Officer.

We are not required to agree with your request. If we do agree, we will comply with your additional restrictions or confidential communications request.

Right to a Paper Copy of this Notice. You have the right to a paper copy of this privacy notice.

Personal Representatives

You may exercise your rights through a personal representative. Your personal representative will be required to produce evidence of his/her authority to act on your behalf before that person will be given access to PHI about you or allowed to take any action for you. Proof of such authority may take one of the following forms:

• A power of attorney for health care purposes, notarized by a notary public;
• A court order of appointment of the person as the conservator or guardian of the Patient;
• A Patient who is the parent of a minor child.

We retain the discretion to deny access to PHI about you to a personal representative to provide protection to those vulnerable Patients who depend on others to exercise their rights under this Notice and who may be subject to abuse or neglect. This also applies to personal representatives of minors.

Privacy Regulations

Federal and state law, including the Health Insurance Portability and Accountability Act (HIPAA), regulates our use and disclosure of PHI about you. The HIPPA regulations are set forth in the United States Code of Regulations at 45 CFR Parts 160 and 164. This Notice attempts to summarize the regulations. The regulation will supersede any discrepancy between the information contained in this Notice and the regulations.

Complaints/Contract Information

If you believe your privacy rights have been violated, you may contact or submit your complaint in writing to our Privacy Officer (listed below). You have the right to file a written complaint with the Secretary of the United States Department of Health and Human Services. We will not intimidate, threaten, coerce or discriminate against a Patient for filing a complaint or otherwise exercising legal rights set forth in this Notice, our Privacy Policy or applicable law.

As of April 14^th, 2003, our Privacy officer is: Cathy Crowley

She may be contacted by phone: 404-350-5780

By fax: 404-350-5640

By U.S. Mail at: Pavilion Compounding Pharmacy

3193 Howell Mill Road Suite 122S

Atlanta, GA 30327