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If we agree to a restriction or limitation of your PHI, the restriction or limitation will not prevent us from disclosing your PHI as follows: (1) to you if you request access to your PHI or if you request an accounting of disclosures; (2) for purposes required or permitted by law; or (3) in the case of an emergency. You have the right to request receipt of PHI from us by alternative means or via alternative locations.For example, you may want to receive communications related to your prescriptions at a different address other than your home address. You have the right of access to inspect and obtain a copy of your PHI; provided, however, you are not entitled to access certain PHI exempted under HIPAA.

If access is ultimately denied, you will be entitled to written explanation of the reasons for the denial. You will receive one request annually free of charge and, thereafter, we may charge you a reasonable, cost-based fee for each subsequent request for an accounting of disclosures within the same twelve-month period.

If this occurs, you have the right to request that your original request, our denial, your statement of disagreement, and our rebuttal be included in future disclosures of your PHI. You have the right at any time to obtain a paper copy of this Notice, even if you receive this Notice electronically. As your neighbors, we live, work and play in the same community as you and your family. Additionally, this Notice explains the rights you have with respect to your PHI, and certain obligations we must abide by in accordance with the law. If we make any material revisions to this Notice, we will post a copy of the revised Notice in the pharmacy or otherwise provide a copy to you. USE AND DISCLOSURE OF YOUR PHI - We will use your PHI for treatment, payment and health care operations.

If you have received an electronic copy of this Notice, but wish to obtain a paper copy of this Notice, please send your request in writing to the Privacy Officer at the address listed below. If you need any additional information about this Notice or wish to exercise any of your rights set forth in this Notice, please contact the Privacy Office at the following address: [INSERT PHARMACY NAME], [INSERT MAILING ADDRESS], and [INSERT PHONE & FAX NUMBER]. If you believe your privacy rights have been violated, you may file a complaint with us or with the Secretary of the Department of Health and Human Services without retaliation. We’re the local business owners you see in the neighborhood, at the school play, and volunteering at the local charity. We may also use your PHI for other purposes that are permitted and/or required by law and pursuant to your written authorization.

it is referring to [INSERT PHARMACY NAME] and all of the pharmacists who provide health care services and the employees of our pharmacy.

We may disclose your PHI to other pharmacists, pharmacy technicians and health care providers that are involved in taking care of you. For Payment - We will also use and disclose your PHI in order to obtain payment for the health care services we provide to you.

If we do not have your PHI in our possession, we will provide you with the appropriate contact information when we receive your request.

We will respond to your request for an amendment no later than sixty (60) days after we receive your request. it is referring to [INSERT PHARMACY NAME] and all of the pharmacists who provide health care services and the employees of our pharmacy.

to a correctional institution or law enforcement custodian; and ? You have the right to request restrictions or limitations on how we are allowed to use and/or disclose your PHI, however, we do not have to agree to your requested restriction or limitation (except to the extent required by the Recovery Act for certain cash transactions).

to the extent necessary to comply with laws relating to workers' compensation. YOUR RIGHTS AS OUR PATIENT - As our patient, you have a number of rights associated with your PHI. Your written request must specify: (1) if you would like to restrict or limit our use, disclosure or both; (2) what information you would like to restrict or limit; and (3) to whom you want the limitation or restriction to apply (e.g., your spouse).

This Notice describes how we may use and disclose your PHI.

We are required by law to maintain the privacy of your protected health information ("PHI"), to follow the terms of this Notice, and to give you this Notice setting forth our legal duties and privacy practices concerning your PHI.

to organ procurement organizations or similar entities for the purpose of facilitating organ, eye or tissue donation and transplantation; ? to avert a serious threat to health or safety, so long as the disclosure is only to a person who is reasonably able to prevent or lessen such threat; ?

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