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«Serving Colorado’s Front Range The Kingfisher, calm and at peace, nested upon water, quieter of restlessness. A Patient & Family Guide to Hospice ...»

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We reserve the right to change this notice at any time and to make the revised or changed notice effective for PHI that we already have about you as well as any information we receive in the future about you. Should we revise/change this Privacy Notice, we will make this notice available to you upon request You may request and obtain a copy of any new/revised Privacy Notice from the contact person identified on the last page of this notice.

Should you have questions concerning our Privacy Notice, our contact information is listed on the last page of this document.

II. Examples of How We Use and Disclose Protected Health Information about You The following categories describe different ways that we use and disclose your protected health information. We have provided you with examples in certain categories; however, not every use or disclosure in a category will be listed.

Treatment. We may use your health information to provide and coordinate the treatment, medications and services you receive. For example, we may contact you regarding compliance programs such as drug recommendations, therapeutic substitution, refill reminders, other product recommendations, counseling and drug utilization review (DUR), product recalls or disease state management.

Payment. We may use your health information for various payment-related functions. Example:

We may contact your insurer, pharmacy benefit manager or other health care payor to 58 A Patient & Family Guide to Hospice Care

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Food and Drug Administration (FDA). We may disclose to the FDA, or persons under the jurisdiction of the FDA, 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.

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Public Health. As required by law, we may disclose your PHI to public health or legal authorities charged with preventing or controlling disease, injury, or disability.

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As Required by Law. We will disclose your PHI when required to do so by federal, state, or local law.

Health Oversight Activities. We may disclose your PHI to an oversight agency for activities authorized by law. These oversight activities include audits, investigations, inspections, and credentialing, as necessary for licensure and for the government to monitor the health care system, government programs, and compliance with civil rights laws.

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Research. We may disclose your PHI to researchers when their research has been approved by an institutional review board or privacy 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 your PHI 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 enable them to carry out their duties.

Organ or Tissue Procurement Organizations. Consistent with applicable law, we may disclose your PHI 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 your PHI to notify or assist in notifying a family member, personal representative, or another person responsible for your care, regarding your location and general condition.

Fundraising. We may contact you as part of a fundraising effort.

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 other individuals.

To Avert a Serious Threat to Health or Safety. We may use and disclose your PHI 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 foreign military authority.

National Security, Intelligence Activities, and Protective Services for the President and Others. We may release PHI about you to federal officials for intelligence, counterintelligence, protection to the President, and other national security activities authorized by law.

Victims of Abuse or Neglect. We may disclose PHI about you to a government authority if we reasonably believe you are a victim of abuse or neglect. 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.

Other Uses and Disclosures of PHI We will obtain your written authorization before using or disclosing your PHI for purposes other than those provided for above (or as otherwise permitted or required by law). You may revoke an authorization in writing at any time. Upon receipt of the written revocation, we will stop using or disclosing your PHI, except to the extent that we have already taken action in reliance on the authorization.

60A Patient & Family Guide to Hospice Care

III. Your Rights Regarding Your Protected Health Information Obtain a paper copy of the Notice upon request. You may request a copy of our current Notice at any time. You may obtain a paper copy from our business office.

Request a restriction on certain uses and disclosures of PHI. You have the right to request additional restrictions on our use or disclosure of your PHI by sending a written request to our business office. We are not required to agree to those restrictions. We cannot agree to restrictions on uses or disclosures that are legally required, or which are necessary to administer our business.

Inspect and obtain a copy of PHI. In most cases, you have the right to access and copy the PHI that we maintain about you. To inspect or copy your PHI, you must send a written request to our business office. We may charge you a fee for the costs of copying, mailing and supplies that are necessary to fulfill your request. We may deny your request to inspect and copy in certain limited circumstances.

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. To request an amendment, you must send a written request to our business office. You must include a reason that supports your request. In certain cases, we may deny your request for amendment.

Receive an accounting of disclosures of PHI. You have the right to receive an accounting of the disclosures we have made of your PHI after April 14, 2003 for most purposes other than treatment, payment, or health care operations. The right to receive an accounting is subject to certain exceptions, restrictions, and limitations. To request an accounting, you must submit a request in writing to the business office. Your request must specify the time period. The time period may not be longer than six years and may not include dates before April 14, 2003.

Request communications of PHI by alternative means or at alternative locations. For nstance, you may request that we contact you at a different residence or post office box. To request confidential communication of your PHI, you must submit a request in writing to our business office. Your request must tell us how or where you would like to be contacted. We will accommodate all reasonable requests.

Where to obtain forms for submitting written requests. You may obtain forms for submitting written requests by contacting the business office at SeniorMed, 480 S. Chambers Rd. Aurora, CO 80017 or toll-free by telephone at 888. 736.6331 Minors. If you are a minor who has lawfully provided consent for treatment and you wish for SeniorMed to treat you as an adult for purposes of access to and disclosure of records related to such treatment, please notify a pharmacist or the Privacy Office.

IV. How to File a Complaint about Our Privacy Practices If you have reason to believe that we have violated your privacy rights or our privacy policies and procedures, or if you disagree with a decision we made concerning access to your protected health information, you have the right to file a complaint with us or the Secretary of the U.S. Department of Health and Human Services. You will not be retaliated against for filing a complaint.

You may submit your complaint directly to SeniorMed. Our contact information is listed on the last page of this document.

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Notice of Privacy Practices Record of Acknowledgment / Documentation of Good Faith Effort to Obtain Acknowledgment Name of [Resident/Patient]: ____________________________________________ Date: ________________________

Effective Date of This Privacy Notice The effective date of this Privacy Notice is April 14, 2003 Contact Information for Questions, Complaints or Requests Regarding Your Health Information Should you have any questions concerning our privacy practices, obtaining a copy of our privacy notice, requesting restrictions on the release of your information, revoking an authorization, amending or correcting your protected health information, obtaining an accounting of our disclosures of your protected health information, requesting inspection or copying of your medical information, requesting that we communicate information about your health matters in a certain way, filing complaints, or any other concerns you may have relative to our privacy

practices, please contact:

Sylvia Brothers 480 S. Chambers Aurora, CO 80017 888. 736.6331 If you wish, you may also file a complaint with the Secretary of the U.S. Department of Health and Human Services. You may mail your complaint to U.S. Department of Health and Human Services, 200 Independence Avenue, S.W., Washington, DC 20201.

Acknowledgment / Good Faith Effort to Obtain Acknowledgment (check one of the following) [ ] I certify that I received a copy of the above-named entity’s Privacy Notice and that I have had an opportunity to review this document and ask questions to assist me in understanding my rights relative to the protection of my health information. I am satisfied with the explanations provided to me and I am confident that the above-named entity is committed to protecting my health information.

Date _____________________ Signature: ___________________________________________________________________

Printed Name: _______________________________________________________________

62 A Patient & Family Guide to Hospice Care [ ] I certify that I am the authorized representative of above-identified patient, and that I have received the Privacy Notice on behalf of this individual and that the above-named entity provided me with an opportunity to review this document and ask questions to assist me in understanding the patient’s privacy rights. I am satisfied with the explanations provided to me and I am confident that the above-named entity is committed to protecting health information.

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[ ] I, ___________________, certify that I made a good faith effort to obtain the acknowledgment of the above-identified [resident/patient] or his/her personal representative that he/she had received a copy of the Privacy Notice of the above-identified entity, but was unable to obtain such

acknowledgment for the following reason(s):

[ ] [Resident/Patient] or personal representative refused to sign.

[ ] [Resident/patient] or personal representative was unavailable to sign.

[ ] Other: _______________________________________________________________________________________________

Date: ____________________ Signature/Title: _____________________________________________________________

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This notice decribes how medical information about you may be used and disclosed and how you can get access to this information. PLEASE REVIEW IT CAREFULLY.

Under applicable law, we are required to maintain the privacy of your Protected Health Information (PHI) and to provide you with notice of our legal duties and privacy practices with respect to PHI.

We are required to abide by the terms of this notice as it may be updated from time to time.

1. Good Day Pharmacy may use or disclose your PHI without your authorization in certain circumstances: We are permitted to make certain types of uses and disclosures of your PHI under applicable law. We may obtain information to dispense prescriptions and for the documentation of information in your records that may assist us in managing your medication therapy or your overall health.

For treatment purposes: We will use PHI to dispense prescriptions to you. PHI will also be used to communicate with your health care providers and to coordinate and manage your health care, for example, when we consult with your physician or specialist regarding your medications, treatment or condition.

For payment purposes: Use and disclosure of PHI will take place to obtain payment or reimbursement for pharmaceutical services, for example, when your case is reviewed to insure appropriate care was delivered. For reimbursement, your PHI may be disclosed to intermediaries employed by your plan sponsor, such as insurers, pharmacy benefit managers, claims administrators and computer switching companies. We may also disclose PHI about you to Good Day Pharmacy’s business associates for services that they may provide to or for Good Day Pharmacy.

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