HIPAA NOTICE OF MEDICAL 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 RESPONSIBILITIES

The Pharmacy is required by law to maintain the privacy of your Protected Health Information (“PHI”) and to provide individuals with notice of our legal duties and privacy practices with respect to PHI. We will not use or disclose PHI about you without your written authorization, except as described in this Notice. The Pharmacy is required to notify affected individuals following a breach of their unsecured PHI. PHI is information about you, including basic 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. This Notice of Privacy Practices (“Notice”) describes how we may use and disclose PHI about you 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 with respect to PHI about you.

The Pharmacy is required to follow the terms of this Notice, which may be amended from time to time. 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:

Right to a Personal Representative. You may identify persons to us who may serve as your authorized personal representative, such a court-appointed guardian, a properly executed and specific power-of-attorney granting such authority, a Durable Power of Attorney for Health Care if it allows such person to act when you are able to communicate on your own, or other method recognized by applicable law.

Right to Request Restrictions. You have the right to request restrictions on our use or disclosure of PHI about you by sending a written request to Acme Pharmacy, HIPAA Privacy Officer, 2700 Gilchrist Road, Akron, Ohio 44305 or at (330) 733-2263 EXT. 55372. We are not required to agree to those restrictions except for a request to restrict the disclosure of PHI about the individual to a health plan if the disclosure is for the purpose of carrying out payment or health care operations and is not otherwise required by law, and the PHI pertains solely to a health care item or service for which the individual has paid out of pocket in full.

Right to Receive Confidential Communications. You have the right to request that we communicate with you in a confidential manner. For example, you may ask us to conduct communications pertaining to your health information only with you privately, with no other family members present or you may request that we contact you about medical matters only in writing or at a different residence or post office box. If you wish to receive confidential communications, send a written request to Acme Pharmacy, HIPAA Privacy Officer, 2700 Gilchrist Road, Akron, Ohio 44305 or at (330) 733-2263 EXT. 55372. We may not require that you provide an explanation for your request and will attempt to honor any reasonable requests.

Right to Inspect and Copy Your PHI. You have the right to access and copy PHI about you contained in a designated record set for as long as the 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 Acme Pharmacy, HIPAA Privacy Officer, 2700 Gilchrist Road, Akron, Ohio 44305 or at (330) 733-2263 EXT. 55372. We may charge you a fee for the costs of copying, mailing and supplies that are necessary to fulfill your request. If the PHI that is the subject of a request is maintained in one or more designated record sets electronically and if you request an electronic copy of such information, we will provide you with access to the PHI in the electronic form and format requested if readily producible in such form and format; or, if not, in a readable electronic form and format as agreed upon by us and you. 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.

Right to Amend Your PHI. You have the right to request that we amend your records, if you believe that your PHI is incorrect or incomplete. That request may be made as long as we maintain the PHI. To request an amendment, you must send a written request to Acme Pharmacy, HIPAA Privacy Officer, 2700 Gilchrist Road, Akron, Ohio 44305 or at (330) 733-2263 EXT. 55372. You must include a reason that supports your request. We may deny the request if it is not in writing, or does not include a reason for the amendment. The request also may be denied if your health information records were not created by us, if the records you are requesting are not part of our records, if the health information you wish to amend is not part of the health information you are permitted to inspect and copy, or if, in our opinion, the records containing your health information are accurate and complete. We take the position that amendments may take the form of including a written statement from you and may not include changing, defacing or destroying any necessary information related to your health care.

Right to Receive an Accounting of Disclosures of PHI. You have the right to receive an accounting of the disclosures we have made of PHI about you for the six years prior to the date on which the accounting is requested for most purposes other than treatment, payment, or health care operations. The accounting will exclude certain disclosures, such as disclosures we have made directly to you, disclosures you authorize, 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 writing to Acme Pharmacy, HIPAA Privacy Officer, 2700 Gilchrist Road, Akron, Ohio 44305 or at (330) 733-2263 EXT. 55372. 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 the 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.

Right to Obtain a paper copy of the Notice upon request. You may request a paper 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 Acme Pharmacy, HIPAA Privacy Officer, 2700 Gilchrist Road, Akron, Ohio 44305 or at (330) 733-2263 EXT. 55372.

HOW WE MAY USE AND DISCLOSE PHI

The following are descriptions and examples of ways we use and disclose PHI:

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 copayment. We will bill you or a third-party payor 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: The 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 our accountants and pharmacy software company. 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 payor 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 identify, PHI relevant to that person’s involvement in your care or payment related to your care.

Health-related 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 person under the jurisdiction of the FDA, its agents 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 replacement.

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 pursuant to legal process. As required by law: We must disclose PHI about you when required to do so by law.

Health oversight activities: We may 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 a 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 a court order protecting the requested PHI.

WE ARE PERMITTED TO USE OR DISCLOSE PHI ABOUT YOU FOR THE FOLLOWING PURPOSES:

Research: We may disclose PHI about you to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your information.

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.

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 or 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.

For Specified Government Functions: Federal regulations may require or authorize us to use or disclose your PHI to facilitate specified government functions relating to military and veterans; national security and intelligence activities; protective services for the President and others; medical suitability determinations; and inmates and law enforcement custody.

Victims of abuse, neglect, or domestic violence: We may disclose PHI about you to a government authority, such as a social service or protective services 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, or 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: The Pharmacy will obtain your written authorization before using or disclosing PHI about you for purposes other than those provided for above (or as otherwise permitted or required by law). You may revoke this 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.

WHERE TO FILE A COMPLAINT

You have the right to complain to us if you believe that your privacy rights have been violated, including the denial of any rights set forth in this Notice. Any complaints to us shall be made in writing to the Acme Pharmacy, HIPAA Privacy Officer, 2700 Gilchrist Road, Akron, Ohio 44305. We encourage you to express any concerns you may have regarding the privacy of your information. You will not be retaliated against in any way for filing a complaint.

You may also file a written complaint with the Secretary of the U.S. Department of Health and Human Services, 200 Independence Avenue SW, Washington, D.C., 20201 or call toll-free (877) 696-6775, by e-mail to OCRComplaint@hhs.gov, or to Region V, Office for Civil Rights, U.S. Department of Health and human Services, 233 N. Michigan Ave., Suite 240, Chicago, Ill. 60601, Voice Phone (312) 886-2359, FAX (312) 886-1807, or TDD (312) 353-5693.

CONTACT PERSONS

If you have questions or would like additional information about the Pharmacy’s privacy practices, you may contact Acme Pharmacy, HIPAA Privacy Officer, 2700 Gilchrist Road, Akron, Ohio 44305 or at (330) 733-2263 EXT. 55372.

EFFECTIVE DATE

This Notice is effective September 23, 2013.