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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.

Your Rights
You have the following rights with respect to your Protected Health Information (PHI) when it comes to your health information. This notice explains how we will use and disclose your PHI while maintaining your privacy and explains our duty to abide by the terms of the notice and any update that we may make in the future.

  1. The right to request restrictions on certain uses and disclosures, including any group of person(s) identified by you. We are, however, not required to agree to a requested restriction.
    • You can ask us not to share your health information with family or friends involved in your treatment.
    • You can ask us not to share or use your health information for treatment, our operations, or payments
    • We are also not required to agree to your request, if it would negatively affect your health we are authorized to say “no”.
  2. The right to reasonable requests to receive confidential communications from us by alternative
    locations.
    • We will accept all reasonable requests and must say “yes” if you inform us that your life is in danger if we do not.
    • You can ask us to contact you in other ways (for example, cell or work phone) or to send mail to a different address.
  3. The right to inspect and copy Protected Health Information (PHI). We reserve the right to schedule this activity and charge a reasonable fee to gather the information and copy for expenses.
    • We will provide a copy of your health and claims records, usually within 30 days (60 days if the information is stored off-site) of your request. We may also charge a reasonable fee.
    • You can ask to see or get a copy of your health and claims records or any other health information we may have about you. Please ask us how to go about this process.
    • We can deny your request of copies or to see your health information in certain situations. For example, we can deny your request if we believe the disclosure will endanger your health or life or that of another person
  4. The right to amend your Protected Health Information (PHI).
    • You can ask us to amend your health and claims records if you believe they are incorrect or
      incomplete please ask us how to go about this process.
    • Your right to ask us to amend your records lasts for as long as we maintain this information.
    • We can deny your request, we will then mail you the reason for our denial within 60 days.
  5. The right to receive a list of disclosures of your Protected Health Information (PHI) when you complete our request form.
    • We will provide all the disclosures except for those about treatment, health care operations,
      payment, and certain other disclosures (such as any you asked us to make). We will provide
      one accounting a year for free but will charge a reasonable fee if you ask for another one within
      12 months.
    • You can ask for a list (accounting) of the times we have shared your health information for 6
      years prior to the date you ask, who we shared it with, and why.
  6. The right to obtain a paper copy of this notice.
    • You can ask for a paper copy of this notice at any time. We will provide you with a paper copy
      promptly.

You have Choices

  1. You have the right to have someone act for you.
    • If you have given someone medical power of attorney or if someone is your legal guardian, that person may exercise your rights and make choices about your health information. We will ensure the person has this authority and can act for you before we take any action.
  2. For specific health information, you can tell us your choices about what we share. If you have a preference on how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions. In these cases, you have both the right and choice to tell us to:
    • Share your information with family, friends, or others involved in your care
    • Share your information with family, friends, or others who are financially responsible for payment of your care.
    • Share information in the event of a disaster relief situation.

If you are not capable of telling us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety. We will never share your information for marketing purposes or to sell your information without your written consent.

Our Use of Your Information and Disclosures

Under the law we are permitted to use and disclose your Protected Health Information (PHI) without your authorization for the following purposes:

  1. Managing your care treatment
    • We can contact your physician or other health care providers to obtain refill authorizations, clarify medication doses, inform them of potential drug interactions, or to validate and verify prescription orders
    • We can use your health information and share it with other professionals who are treating you.
  2. Run our business operations
    • We can use and disclose your health information for running our business, such as planning, managing your treatment and services, improvement purposes, financial analysis, and customer service.
    • We look at your records to evaluate how well our pharmacists and technicians provide service to you.
  3. Bill for your health care services
    • We can use and disclose your health information to obtain payment for services, confirming health plan coverage, and billing or collection activities.
    • Insurance companies and health plans may also contact us about services we provide to you.

Other ways we share and use your health information

We are required to obtain your written consent to use or disclose your Protected Health Information (PHI) for other purposes not related to treatment, health care operations, or payment. However, we are occasionally permitted or required to share your information in other ways such as public health and research. We have to meet many conditions in the law before we can share your information. For more information please visit: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.

  1. We may use your Protected Health Information (PHI) without your consent to provide you with refill reminders; information about alternatives to medications or services you receive through Mini; or notices of health screenings, special events, or other wellness activities we may conduct.
  2. We may release information about you to a family member or others who are involved in your medical care.
  3. Whenever anyone receives Protected Health Information (PHI) on your behalf we will provide only the minimum amount of information necessary to ensure your quality of care.
  4. We may disclose Protected Health Information (PHI) about you for law enforcement purposes as required by law or in response to a court or administrative order, or in response to a subpoena.
    Other ways we share and use your health information cont’d
  5. We may use and disclose your Protected Health Information (PHI) when necessary to reduce or prevent serious threat to your health and safety or of another individual or the public. We may also share information about you in situations such as preventing disease, product recalls, reporting adverse reactions to medications, and reporting suspected abuse, neglect, or domestic violence.
  6. We may disclose your Protected Health Information (PHI) if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law.
  7. We may release your Protected Health Information (PHI) with a coroner, medical examiner, funeral director when an individual dies, or organ procurement organizations..
  8. We may use and disclose your Protected Health Information (PHI) for workers’ compensation claims, special government functions such as military, national security, and presidential protective services and with health oversight agencies for activities authorized by law.
  9. Any other uses and disclosures other than those provided for above (or as otherwise permitted or required by law) will be made only with your written consent. You may revoke such authorization in writing and we are required to honor and abide by that written request, except for actions we have already taken relying on your consent.

Our Responsibilities

  1. We are required by law to maintain the privacy and security of your Protected Health Information (PHI) and to provide you with notice of our legal duties and privacy practices with respect to protected health information.
  2. We will inform you if a breach occurs that may have compromised the privacy or security of your health information promptly.

Changes to Our Terms of this Notice

This notice is effective as of June 6,2019 and we are required to abide by the terms of this Notice of Privacy Practices currently in effect.

  1. We reserve the right to change the terms of this notice and to make the new notice provisions
    effective for all protected health information that we maintain.
  2. We will post any revised notice in our pharmacy and you may receive a written copy of a
    revised notice upon your request.

Our Complaint Process

Our Complaint ProcessIf you believe your privacy has been violated, you have the right to file a formal complaint with us by contacting us at 1 (888) 545-6464 or with the U.S Department of Health and Human Services Office of Civil Rights. You may also file a complaint with us by filling out our client/patient complaint form that has been provided for you in this packet. We will not retaliate against you for filing a complaint.

Contact Information
Mini Pharmacy & Medical Supplies
2425 Porter Street
Los Angeles, CA 90021
1 (888) 545-6464
Compliance Officer, Karina Ruesga.

I understand that under HIPAA regulations, I have the right to request that Mini Pharmacy restrict how protected private health information about me is used or disclosed on the Patient Consent form, a document separate from this acknowledgement.