Custom Rx Compounding Pharmacy Notice of Privacy Policy

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.

We understand the confidential nature of the information you provide to Custom Rx Compounding Pharmacy. We want you to understand how we may use and disclose certain information you provide to us, and what rights you have concerning that information. The privacy policy will tell you:

1. What information is protected
2. How Custom Rx Compounding Pharmacy may use and disclose your protected information.
3. Your rights concerning your protected information.

Information protected by this policy includes information Custom Rx Compounding Pharmacy receives or creates that identifies you and concerns:

1. Your past, present, or future medical health or condition.
2. Medical care that is provided to you.
3. The past, present, or future payment for medical care to you.

Custom Rx Compounding Pharmacy may use or disclose your protected information to provide you with treatment, obtain payment for your treatment, or perform health care operations. Some examples of how we may use or disclose your protected information for these reasons are:

Treatment: We may use or disclose your protected information to dispense prescription medications or devices to you, provide you with information and counseling on your drug therapy, and communicate with your physician, your physician’s staff, emergency treatment personnel or other health care professionals to ensure you receive appropriate treatment.

Payment:  We may use or disclose your protected information to assist reimbursement for your treatment from your insurer or pharmacy benefit manager.

Health Care Operation. We may use or disclose your protected information to review the performance of our pharmacists and technicians to prevent fraud and to develop compliance programs in order to offer more effective and comprehensive treatment to you.

Custom Rx Compounding Pharmacy may also use or disclose your protected information for other reasons.
Those reasons and some examples are:

Communications with you:  We may use your protected information to contact you. We may contact you to ensure the prescription is working effectively, or to provide you with information about alternative treatment options.

Health Oversight Agencies:  We may disclose your protected information to agencies authorized by law to perform audits, investigations or inspections for the oversight of the health care system, government benefit programs, government regulatory programs or civil rights laws.

Judicial and Administrative proceedings:  We may disclose your protected information in response to a court order, administrative order, subpoena, warrant or other lawful process.

Law enforcement:  We may disclose your protected information as required by law in response to requests from law enforcement.

Services:  We may hire third parties to perform certain services for us. We may disclose your protected information to these third parties so they can perform the services we ask them to. These third parties will be required to protect your information and will not be allowed to use your information for any other purpose other than to provide the services we have requested.

Special Circumstances:  We may disclose your protected information in certain special circumstances including but not limited to: agencies authorized by law to collect information for national security and intelligence activities, specialized government functions in the event you are a veteran or in the military, for investigation of death or identification of a  deceased person, for the review of product quality and safety, to avert a threat to health or safety or individual or the public, or to comply with the requirements for worker’s compensation programs.

These examples are given as illustration only. They may not be all-inclusive. Custom Rx Compounding Pharmacy may also use or disclose your protected information as otherwise required by law. Custom Rx Compounding Pharmacy may also use or disclose your protected information as otherwise required by law. Custom Rx Compounding Pharmacy will obtain your written authorization before using or disclosing your protected information for any other reason other than those included in this notice. You may revoke your authorization in writing at any time. Upon receipt of your written revocation, we will stop using or disclosing your protected information, except to the extent that we have already taken action in reliance on the authorization.

Your Rights
You have certain rights concerning your protected information and this notice. These rights include:
Notice:  You may request a copy of this notice at anytime. To request a paper copy, call or visit Custom Rx Compounding Pharmacy.

Inspection and copies:  You have the right to inspect and receive a copy of the protected information we maintain about you. To do so you may submit a written request of the information you need. There may be a fee for copying and mailing your protected information.

Amendments:  If you feel that the protected information we maintain about you is incomplete or incorrect, you may request that we amend it. To request an amendment contact Custom Rx Compounding Pharmacy. Your amendment may or may not require a written request including the reason for the amendment. In certain cases, we may deny your request for such an amendment. If your request for amendment is denied you may send us a written statement disagreeing with our denial.

Restrictions on uses and disclosures:  You have the right to request additional restrictions on our use or disclosure of your protected information. Your request must be submitted in writing. We are not required to agree to any restrictions you request.

Accounting of disclosures:  You have the right to receive an accounting of the disclosures we have made. The accounting will not include disclosures made for treatment, payment or health care operations, disclosures made directly to you, your friends or family members involved in your care, or disclosures authorized by you.
The right to receive an accounting of disclosures is subject to other exceptions, restrictions, and limitations. You may submit a written request at any time. There may be a fee for the accounting of disclosures. We will notify you of the fee prior to providing the accounting of disclosures list.

Alternative Communications:  You may request that we contact you about your protected information only in writing or at a different residence. We will accommodate reasonable requests. To make a request you must submit your request in writing.

For More Information or to Report a Problem
If you have questions or would like additional information about the Custom Rx Compounding Pharmacy privacy policy contact the HIPAA Administrator at 612-866-2211. To file a complaint you may send your complaint to Custom Rx Compounding Pharmacy, c/o HIPAA Administrator, 6519 Nicollet Ave S Ste 201, Richfield, MN 55423. There will be no retaliation against you for filing a complaint.
Revisions to Notice

Custom Rx Compounding Pharmacy may revise the terms of this notice and make the new notice effective for all your protected information. If we make a change to this notice, a new notice will be available to you upon your request.

Effective Date
This notice is effective as of April 14, 2003.

Custom Rx Compounding Pharmacy is required by law to maintain the privacy of your protected information and to provide you with this notice. We are required to comply with the terms of this notice for as long as it is in effect.

Custom Rx Compounding Pharmacy has never and will never sell your information to any company for any purposes including marketing and telemarketing.

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The health insurance Portability and Accountability Act of 1996 (HIPAA) requires that we provide you with this privacy notice. Additionally we are required to ask you to sign an acknowledgement that you have received this notice. We are required to maintain these signatures on file. Please complete the lines below and return to us by mail, fax or in person.

Name_______________________________________

Address_____________________________________                      

City, State, Zip_________________________________

Telephone___________________________________                       

Email________________________________________

Signature____________________________________                       

Date_________________________________________