PRIVACY STATEMENT
Market Compounding Pharmacy
9250 Reseda Blvd. �� Unit 2C��
Northridge, Ca 91324
818-701-7777 800-771-1110 fax 818-700-4510
Valued Patient/Customer,
As of April 14, 2003, we are required by the Federal Government
to inform you of our Privacy Practice.
Please read the following document and complete the form at the
end of this document and either mail the completed acknowledgement to us or fax
to 818-700-4510. Please print this page and keep it as your record of the
Privacy Practice.
Thank you for your patronage,
Armen Tatevossian
Owner and President
NOTICE OF 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.
The Pharmacy is required to maintain the privacy of your
Protected Health Information ("PHI") and to provide you with a notice of our
legal duties and privacy practices with respect to 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 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. We
will not use or disclose PHI about you without your written authorization,
except as described in this Notice. We reserve the right to change our practices
and this Notice and to make the new Notice effective for PHI we maintain. Upon
request, we will provide a revised Notice to you.
Your Health Information Rights
You have the following rights with respect to PHI about you:
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Obtain a paper copy of the Notice upon request. You may
request a 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
copy, contact the "Privacy Officer" whose name appears at the end of this
notice.
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Request a restriction on certain uses and disclosures of
PHI. You have the right to discuss any concerns related to the privacy of
your PHI and make a request for additional restrictions on our use or
disclosure of PHI about you or for additional confidential treatment of
communications. We are not required to agree to those restrictions.
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Inspect and obtain a copy of 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 the "Privacy Officer" whose name appears at
the end of this notice. We may charge you a fee for the costs of copying,
mailing or other supplies that are necessary to grant your request. 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.
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Request an amendment of PHI. If you feel that PHI we
maintain about you is incomplete or incorrect, you may request that we amend
it. You may request an amendment for as long as we maintain the PHI. To
request an amendment, you must send a written request to the "Privacy Officer"
whose name appears at the end of this notice. In addition, you must include a
reason that supports your request. In certain cases, we may deny your request
for amendment. If we deny your request for amendment, you have the right to
file a statement of disagreement with the decision and we give you a rebuttal
to your statement.
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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 after April 14, 2003, for most purposes other than treatment,
payment or health care operations. The accounting will exclude disclosures we
have made directly to you, 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 your request in writing
to the "Privacy Officer" whose name appears at the end of this notice. Your
request must specify the time period, but may not be longer than six years.
You may be charged for the cost of providing an accounting. We will notify you
of the cost involved and you may choose to withdraw or modify your request at
that time.
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Request communications of PHI by alternative means or at
alternative locations. For instance, you may request that we contact you
about medical matters only in writing or at a different residence or post
office box. To request confidential communication of PHI about you, you must
submit your request in writing to the "Privacy Officer" whose name appears at
the end of this notice. Your request must state how or when you would like to
be contacted. We will accommodate all reasonable requests.
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Revoke your consent to use or disclose PHI. You may
revoke a consent 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 consent. We may
refuse to continue to treat a customer that revokes his or her consent.
Examples of How We May Use and Disclose PHI Without Your
Written Consent
The following categories describe and provide examples of
different ways that we use and disclose PHI about you without your written
consent.
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 co-payment responsibility. 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 without your written
authorization for the following purposes:
Business associates: There are some services provided by
us through contracts with business associates. Examples include our software
system vendor and technology provider Etreby Computer Company. When these
services are contracted for, we may disclose PHI about you to our business
associate 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
enter into written contracts and require satisfactory assurance from 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.
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 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, repair or replacement.
Worker's compensation: We may disclose PHI about you to
the extent authorized by and to the extent necessary to comply with lawas
relating to worker's compensation or other 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 in response to a valid subpoena.
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 activites 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 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 obtain an order protecting the requested PHI.
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 general condition.
Correctional institution: If you are or become an inmate
of a correctional institution we may disclose to the institution or its agents
PHI necessary for your health and 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.
Military and veterans: If you are a member of the armed
forces, we may release PHI about you as required by military command
authorities. We may also release PHI about foreign military personnel to the
appropriate military authority.
National security and intelligence activities: We may
release PHI about you to authorized officials for intelligence,
counterintelligence and other national security act ivies authorized by law.
Protective services for the President and others: We may
disclose PHI about you to authorized federal officials so they may provide
protection to the President, other authorized persons or foreign heads of state
or conduct special investigations.
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 Requiring Your Written
Authorization
The pharmacy will ontain 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.
For More Information or to Report a Problem
If you have questions or would like additional information about
the Pharmacy's privacy practices, you may contact the "Privacy Officer" whose
name appears at the end of this notice at the pharmacy address and telephone
number at the top of this page.
If you belive your privacy rights have been violated, you can
file a complaint with the "Privacy Officer" whose name appears at the end of
this notice or with the Secretary of Health and Human Services. There will be no
retaliation for filing a complaint.
Effective Date
This Notice is effective as of February 1, 2003
Privacy Officer: Armen Tatevossian, PHARM.D
(Please click here to go to the
Acknowledgement of Receipt of the Notice of Privacy Practices that may be
mailed or faxed to the pharmacy at the top of the page.)
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