GOVERNORS PHARMACY HIPAA NOTICE OF PRIVACY PRACTICES For Your Protected Health Information

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1 GOVERNORS PHARMACY HIPAA NOTICE OF PRIVACY PRACTICES Fr Yur Prtected Health Infrmatin 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. When this Ntice f Privacy Practices ( Ntice ) refers t we r us, it is referring t GOVERNORS PHARMACY and all f the pharmacists wh prvide health care services and the emplyees f ur pharmacy. We are required by law t maintain the privacy f yur prtected health infrmatin ("PHI"), t fllw the terms f the Ntice currently in effect, t give yu this Ntice setting frth ur legal duties and privacy practices cncerning yur PHI and t ntify affected individuals fllwing a breach f unsecured PHI. This Ntice describes hw we may use and disclse yur PHI. Additinally, this Ntice explains the rights yu have with respect t yur PHI, and certain bligatins we must abide by in accrdance with the law. We reserve the right t amend this Ntice. If we make any material revisins t this Ntice, we will pst a cpy f the revised Ntice in the pharmacy, n ur website and will ffer yu a cpy f the revised Ntice. USE AND DISCLOSURE OF YOUR PHI We will use and disclse yur PHI fr treatment, payment and health care peratins. We may als use yur PHI fr ther purpses that are permitted and/r required by law and pursuant t yur written authrizatin. The fllwing lists examples f hw we may use and/r disclse yur PHI. Any ther uses nt described in this Ntice will nly be made with yur explicit written authrizatin, which yu may revke at any time by prviding us with written ntice f yur revcatin. Treatment - We may use and disclse yur PHI in rder t prvide yu with prescriptin and supply services. We may use and disclse PHI abut yu t prvide, crdinate r manage yur health care services. We may disclse yur PHI t ther pharmacists, pharmacy technicians and health care prviders that are invlved in yur care. Yu will receive an individual ntice and have the pprtunity t pt ut f any subsidized treatment cmmunicatins. Example: Infrmatin that yu r yur physician prvides t the pharmacist will be used t prperly fill yur prescriptin. We will dcument in yur recrd infrmatin related t bth medicatins dispensed t yu and services prvided. Payment - We will use and disclse yur PHI in rder t btain payment fr the health care services we prvide t yu. We may als need t disclse yur PHI t receive prir apprval frm yur health plan r t determine if yur health plan will cver a certain prescriptin r service. Example: We cntact yur insurer r pharmacy benefit manager t determine payment fr yur prescriptin and the amunt f yur c-payment. We bill yu r a third-party payer fr the cst f the prescriptin medicatins dispensed t yu. The infrmatin n the accmpanying bill may include infrmatin that identifies yu, as well as the medicatins yu are taking. Health Care Operatins - We may use and disclse yur PHI in cnnectin with the management f ur pharmacy. This may include: quality assessment and imprvement, internal cmpliance audits, and perfrmance evaluatins. Additinally, we may use yur PHI fr ur business management and general administrative activities. Example: The pharmacy may use infrmatin in yur health care recrd t mnitr the perfrmance f the pharmacists prviding treatment t yu. This infrmatin may be used fr a number f reasns, including ur effrt t cntinually imprve the quality and effectiveness f the health care and services we prvide.

2 Prescriptin Refill Reminders, Treatment Alternatives r Health-Related Benefits - We may use and disclse yur PHI t cntact yu t remind yu abut prescriptin refills, t tell yu abut treatment ptins r alternatives, r t infrm yu abut health-related benefits r services that may be f interest t yu Family Members, Relatives r Clse Friends - Unless yu bject t such disclsure, we may disclse yur PHI t yur family members, relatives r clse persnal friends, r any ther persns identified by yu as being invlved in the treatment r payment fr yur medical care. If yu are nt present t agree r bject t ur disclsure f yur PHI t a family member, relative r friend, we may exercise ur prfessinal judgment t determine whether the disclsure is in yur best interest. If we decide t disclse yur PHI, we will nly disclse the PHI that is relevant t yur treatment r payment. Business Assciates: There are sme services prvided by us thrugh cntracts with business assciates. When these services are cntracted fr, we may disclse PHI abut yu s they can perfrm the jb we have asked them t d and bill yu r yur third-party payer fr services rendered. In rder t prtect yur PHI, we require the business assciate t apprpriately safeguard the infrmatin. Fd and Drug Administratin (FDA): We may disclse t the FDA, r persns under the jurisdictin f the FDA, PHI relative t adverse events with respect t drugs, fds, supplements, prducts and prduct defects, r pst marketing surveillance infrmatin t enable prduct recalls, repairs, r replacements. Other Permitted and Required Uses and Disclsures - We may use yur PHI withut btaining yur authrizatin and withut ffering yu the pprtunity t agree r bject as fllws: as required by law, prvided hwever, that the use r disclsure will be made in cmpliance with applicable law; t a public health authrity that is authrized by law t cllect r receive such infrmatin, r t a freign gvernment agency that is acting in cllabratin with a public health authrity and these health activities generally include preventing r cntrlling disease, reprting deaths, reprting adverse effects f medicatins r prblems with prducts, ntificatin f cmmunicable disease, and reprting abuse r neglect under certain circumstances; t a health versight agency fr versight activities authrized by law, including audits and inspectins, and civil, administrative r criminal investigatins, prceedings r actins; fr judicial r administrative prceedings purpses in respnse t a subpena, curt rder, discvery request, etc. but nly if effrts have been made t infrm yu abut the request r t btain an rder prtecting the infrmatin requested; t law enfrcement t reprt certain injuries, cmply with curt rders r warrants r similar prcess, t identify a suspect, fugitive, missing persn r victim r t reprt a crime; t a crner r medical examiner t perfrm duties authrized by law such as identificatin f a deceased persn r determining the cause f death; t funeral directrs, cnsistent with applicable law, as necessary t carry ut their duties; t rgan prcurement rganizatins r similar entities fr the purpse f facilitating rgan, eye r tissue dnatin and transplantatin; fr research purpses prvided that certain apprvals take place and assurances are given. We may disclse PHI abut yu t researchers when an institutinal review bard that has reviewed the research prpsal and established prtcls t ensure the privacy f yur infrmatin has apprved their research. Gvernrs Pharmacy is nt allwed t receive any mney r ther thing f value in

3 cnnectin with the use r disclsure f yur medical infrmatin fr research purpses unless the mney we receive reflects the csts t prepare and transmit the medical infrmatin t the researcher r unless we seek yur written authrizatin in advance.; Emergencies. We may share with a public r private agency (fr example, the American Red Crss) PHI abut yu fr disaster relief purpses. Even if yu bject, we still may share the PHI abut yu if necessary under the emergency circumstances. t avert a serius threat t health r safety, s lng as the disclsure is nly t a persn wh is reasnably able t prevent r lessen such threat; fr military and veterans activities (including freign military persnnel) t assure the prper executin f a military missin and t determine eligibility fr benefits; fr natinal security and intelligence activities fr the purpse f cnducting lawful intelligence, cunter-intelligence and ther natinal security activities; fr prtectin f the President and ther authrized persns r freign heads f state r t cnduct authrized investigatins; t a crrectinal institutin r law enfrcement custdian if yu are an inmate r under custdy; and t the extent necessary t cmply with laws relating t wrkers' cmpensatin and wrk-related injuries. NORTH CAROLINA STATE LAW If yu receive services in Nrth Carlina, sme Nrth Carlina State laws prvide yu mre prtectin than HIPAA, and where applicable, we will fllw the requirements f thse State laws. The fllwing Nrth Carlina laws may apply t yu: 1. Under Nrth Carlina law, minrs, with r withut the cnsent f a parent r guardian, have the ability t cnsent t services fr the preventin, diagnsis and treatment f certain illnesses including: venereal disease and ther diseases that must be reprted t the State; pregnancy; abuse f cntrlled substances r alchl; and emtinal disturbance. Abrtin services, hwever, still require the cnsent f the parent, guardian r a grandparent with whm the minr has been living fr at least six (6) mnths unless a curt has determined that the minr shuld be treated as an adult. Minrs may petitin a curt t waive this requirement fr parental cnsent. 2. If yu request treatment and rehabilitatin fr drug dependence, yur request will be treated as cnfidential. We will nt disclse yur name t any plice fficer r ther law-enfrcement fficer unless yu cnsent t ur sharing f it. Even if we refer yu t anther persn fr treatment and rehabilitatin, we will cntinue t keep yur name cnfidential. 3. If yu suffer frm a cmmunicable disease (fr example, tuberculsis, syphilis r HIV/AIDS), infrmatin abut yur disease will be treated as cnfidential. Other than circumstances described t yu in ther sectins f this ntice, we will nt release any infrmatin abut yur disease except as required t prtect public health, prevent the spread f a disease, r at the request f the State r Lcal Health Directr. 4. Prescriptin rders n file at ur pharmacies are cnfidential. We will disclse such rders nly t the fllwing peple: Yu, if yu are an adult r a minr wh can cnsent t the treatment described in the prescriptin; Yur guardian; Yur parent if yu are a minr and cannt cnsent t the treatment described in the prescriptin; Yur dctr; Yur pharmacist; A persn t whm yu give written authrizatin; A persn authrized by subpena r a curt s rder;

4 Insurance cmpanies r thers wh pay fr yur prescriptin; Members and emplyees f the Bard f Pharmacy; Peple handling yur estate; and Medical researchers 5. If yur pharmacy shuld clse, fr 30 days befre its clsing yu have the right t have yur files transferred t the pharmacy f yur chice. ALL OTHER USES AND DISCLOUSURES OF PHI Gvernrs Pharmacy will btain yur written authrizatin befre using r disclsing PHI fr purpses ther than thse prvided fr abve r as therwise permitted r required by law. Yu may revke an authrizatin in writing at any time. Upn receipt f the written revcatin, we will stp using r disclsing PHI abut yu, except t the extent that we have already taken actin in reliance n the authrizatin. YOUR RIGHTS AS OUR PATIENT As ur patient, yu have a number f rights assciated with yur PHI. The fllwing describes yur specific rights. 1. Yu have the right t request restrictins r limitatins n hw we use and/r disclse yur PHI, hwever, we d nt have t agree t yur requested restrictin r limitatin (except fr transactins yu paid fr in full ut-f-pcket). Yur written request must specify: (1) if yu wuld like t restrict r limit ur use and/r disclsure; (2) what infrmatin yu want restricted r limited; and (3) t whm the restrictin r limitatin applies (e.g., spuse). 2. If we agree t yur request, it will nt prevent us frm disclsing yur PHI as fllws: (1) t yu if yu request access r an accunting f disclsures; (2) fr purpses required r permitted by law; r (3) in case f an emergency. 3. Yu have the right t receive cnfidential cmmunicatins cncerning yur PHI by alternative means r via alternative lcatins. Fr example, yu may want t receive cmmunicatins related t yur prescriptins at a different address ther than yur hme address. If yu wish t receive cnfidential cmmunicatins via alternative means r lcatins, please submit yur request in writing t the Privacy Officer and set frth the alternative means by which yu wish t receive cmmunicatins r the alternative lcatin at which yu wish t receive such cmmunicatins. We will accmmdate all reasnable requests. 4. Yu have the right t access, inspect and btain a cpy f yur PHI, including any electrnic PHI; prvided, hwever, yu are nt entitled t access certain PHI exempted under HIPAA. T the extent we maintain electrnic PHI, upn request we will prvide yu with a cpy f yur PHI in the frmat requested. If we d nt have yur PHI in ur pssessin, we will prvide yu with the apprpriate cntact infrmatin when yur request is received. If yu request a cpy f yur PHI, yu will receive a respnse t yur request in a timely fashin but may be charged a reasnable, cst-based fee t cver cpy csts and pstage. In sme limited circumstances, we may deny yur request fr access t PHI in which case yu may request fr the denial t be reviewed. If access is ultimately denied, yu are entitled t a written explanatin with the reasn(s) fr the denial. 5. Yu have the right t receive an accunting f disclsures f yur PHI made by us, including disclsures t r by ur business assciate(s), fr a perid f six (6) years prir t the date n which yu request an accunting f disclsures, r such lesser perid as yu indicate. Yu will receive ne request annually free f charge and, thereafter, we may charge yu a reasnable, cst-based fee fr each subsequent request fr an accunting f disclsures within the same twelvemnth perid. We will ntify yu f the cst fr an accunting f disclsures and yu may chse t withdraw r mdify yur request befre we charge yu. 6. If yu believe we have PHI abut yu that is incrrect r incmplete, yu may make a written request t us stating the reasns t supprt any requested amendment. Yu have the right t request an amendment t yur PHI fr s lng as we maintain yur PHI. If we d nt have yur PHI in ur pssessin, we will prvide yu with the apprpriate cntact infrmatin when we receive yur request. We will respnd t yur request fr an amendment after we receive yur

5 request. Hwever, we may deny yur request fr amendment if, fr example, we determine that the PHI yu requested was nt created by us r is already accurate and cmplete. Yu may respnd t ur denial by filing a written statement f disagreement, but we have the right t rebut yur disagreement. If this ccurs, yu have the right t request that yur riginal request, ur denial, yur statement f disagreement, and ur rebuttal be included in future disclsures f yur PHI. 7. Yu have the right at any time t btain a paper cpy f this Ntice, even if yu receive this Ntice electrnically. If yu have received an electrnic cpy f this Ntice, but wish t btain a paper cpy f this Ntice, please send yur request in writing t the Privacy Officer at the address listed belw. 8. Yu have the right t pt-ut f fundraising and yur PHI will nt be used fr fundraising purpses r sld withut yur prir authrizatin. ADDITIONAL INFORMATION AND QUESTIONS If yu need any additinal infrmatin abut this Ntice r wish t exercise any f yur rights set frth in this Ntice, please cntact the Privacy Officer at the fllwing address: GOVERNORS PHARMACY GOVERNORS DR CHAPEL HILL, NC Phne: Fax: If yu believe yur privacy rights have been vilated, yu may file a cmplaint with us r with the Secretary f the Department f Health and Human Services withut retaliatin.

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