NOTICE OF PRIVACY PRACTICES​

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10/01/2018

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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.

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As part of the federal Health Insurance Portability and Accountability Act of 1996, known as HIPAA, the Practice has created this Notice
of Privacy Practices (Notice). This Notice describes the Practice’s privacy practices and the rights you, the individual, have as they relate
to the privacy of your Protected Health Information (PHI). Your PHI is information about you, or that could be used to identify you, as it
relates to your past and present physical and mental health care services. The HIPAA regulations require that the Practice protect the
privacy of your PHI that the Practice has received or created.

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This Practice will abide by the terms presented within this Notice. For any uses or disclosures that are not listed below (Including
Psychotherapy Notes, Marketing and Selling of PHI), the Practice will obtain a written authorization from you for that use or disclosure,
which you will have the right to revoke at any time, as explained in more detail below. The Practice reserves the right to change the
Practice’s privacy practices and this Notice.

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HOW THE PRACTICE MAY USE AND DISCLOSE YOUR PHI

The following is an accounting of the ways that the Practice is permitted, by law, to use and disclose your PHI.

Uses and disclosures of PHI for Treatment: We will use the PHI that we receive from you to fill your prescription and coordinate or
manage your health care.

Uses and disclosures of PHI for Payment: The Practice will disclose your PHI to obtain payment or reimbursement from insurers for
your health care services.

Uses and disclosures of PHI for Health Care Operations: The Practice may use the minimum necessary amount of your PHI to conduct
quality assessments, improvement activities, and evaluate the Practice workforce.

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The following is an accounting of additional ways in which the Practice is permitted or required to use or disclose PHI about you without
your written authorization.

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Uses and disclosures as required by law: The Practice is required to use or disclose PHI about you as required and as limited by law.

Uses and disclosure for Public Health Activities: The Practice may use or disclose PHI about you to a public health authority that is
authorized by law to collect for the purpose of preventing or controlling disease, injury, or disability. This includes the FDA so that it may
monitor any adverse effects of drugs, foods, nutritional supplements and other products as required by law.

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Uses and disclosure about victims of abuse, neglect or domestic violence: The Practice may use or disclose PHI about you to a
government authority if it is reasonably believed you are a victim of abuse, neglect or domestic violence.

Uses and disclosures for health oversight activities: The Practice may use or disclose PHI about you to a health oversight agency for
oversight activities which may include audits, investigations, inspections as necessary for licensure, compliance with civil laws, or other
activities the health oversight agency is authorized by law to conduct.

Disclosures to Individuals Involved in your Care: The Practice may disclose PHI about you to individuals involved in your care.

Disclosures for judicial and administrative proceedings: The Practice may disclose PHI about you in the course of any judicial or
administrative proceedings, provided that proper documentation is presented to the Practice.

Disclosures for law enforcement purposes: The Practice may disclose PHI about you to law enforcement officials for authorized
purposes as required by law or in response to a court order or subpoena.

Uses and disclosures about the deceased: The Practice may disclose PHI about a deceased, or prior to, and in reasonable anticipation of an individual’s death, to coroners, medical examiners, and funeral directors.

Uses and disclosures for cadaveric organ, eye or tissue donation purposes: The Practice may use and disclose PHI for the purpose of
procurement, banking, or transplantation of cadaveric organs, eyes, or tissues for donation purposes.

Uses and disclosures for research purposes: The Practice may use and disclose PHI about you for research purposes with a valid waiver of authorization approved by an institutional review board or a privacy board. Otherwise, the Practice will request a signed
authorization by the individual for all other research purposes.

Uses and disclosures to avert a serious threat to health or safety: The Practice may use or disclose PHI about you, if it believed in good
faith, and is consistent with any applicable law and standards of ethical conduct, to avert a serious threat to health or safety.

Uses and disclosures for specialized government functions: The Practice may use or disclose PHI about you for specialized government
functions including; military and veteran’s activities, national security and intelligence, protective services, department of state
functions, and correctional institutions and law enforcement custodial situations.

Disclosure for workers’ compensation: The Practice may disclose PHI about you as authorized by and to the extent necessary to comply
with workers’ compensation laws or programs established by law.

Disclosures for disaster relief purposes: The Practice may disclose PHI about you as authorized by law to a public or private entity to
assist in disaster relief efforts and for family and personal representative notification.

Disclosures to business associates: The Practice may disclose PHI about you to the Practice’s business associates for services that they may provide to or for the Practice to assist the Practice to provide quality health care. To ensure the privacy of your PHI, we require all business associates to apply appropriate safeguards to any PHI they receive or create.

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OTHER USES AND DISCLOSURES

The Practice may contact you for the following purposes:

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Information about treatment alternatives: The Practice may contact you to notify you of alternative treatments and/or products.

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Health related benefits or services: The Practice may use your PHI to notify you of benefits and services the Practice provides.

Fundraising: If the Practice participates in a fundraising activity, the Practice may use demographic PHI to send you a fundraising packet, or the Practice may disclose demographic PHI about you to its business associate or an institutionally related foundation to send you a fundraising packet. No further disclosure will be allowed by the business associates or an institutionally related foundation without your written authorization. You will be provided with an opportunity to opt-out of all future fundraising activities.

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FOR ALL OTHER USES AND DISCLOSURES

The Practice will obtain a written authorization from you for all other uses and disclosures of PHI, and the Practice will only use or
disclose pursuant to such an authorization. In addition, you may revoke such an authorization in writing at any time. To revoke a
previously authorized use or disclosure, please contact Jennifer Coburn to obtain a Request for Restriction of Uses and Disclosures.

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YOUR HEALTH INFORMATION RIGHTS

The following are a list of your rights in respect to your PHI. Please contact Jennifer Coburn for more information about the below.

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Request restrictions on certain uses and disclosures of your PHI: You have the right to request additional restrictions of the Practice’s
uses and disclosures of your PHI.  The Practice is not required to accommodate a request, except that the Practice is required to agree
to a request to restrict disclosures to health insurance plans related to products and services you pay out-of-pocket for.

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The right to have your PHI communicated to you by alternate means or locations: You have the right to request that the Practice
communicate confidentially with you using an address or phone number other than your residence. However, state and federal laws
require the Practice to have an accurate address and home phone number in case of emergencies. The Practice will consider all
reasonable requests.

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The right to inspect and/or obtain a copy your PHI: You have the right to request access and/or obtain a copy (Paper or Electronic) of
your PHI that is contained in the Practice for the duration the Practice maintains PHI about you. There may be a reasonable cost-based
charge for photocopying documents. You will be notified in advance of incurring such charges, if any.

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The right to amend your PHI: You have the right to request an amendment of the PHI the Practice maintains about you, if you feel that
the PHI the Practice has maintained about you is incorrect or otherwise incomplete. Under certain circumstances we may deny your
request for amendment. If we do deny the request, you will have the right to have the denial reviewed by someone we designate who
was not involved in the initial review. You may also ask the Secretary, United States Department of Health and Human Services (“HHS”),
or their appropriate designee, to review such a denial.

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The right to receive an accounting of disclosures of your PHI: You have the right to receive an accounting of certain disclosures of your
PHI made by the Practice.

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The right to receive additional copies of the Practice’s Notice of Privacy Practices: You have the right to receive additional paper copies
of this Notice, upon request, even if you initially agreed to receive the Notice electronically

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Notification of Breaches: You will be notified of any breaches that have compromised the privacy of your PHI.

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REVISIONS TO THE NOTICE OF PRIVACY PRACTICES

The Practice reserves the right to change and/or revise this Notice and make the new revised version applicable to all PHI received prior
to its effective date. The Practice will also post the revised version of the Notice in the Practice.

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COMPLAINTS
If you believe your privacy rights have been violated, you may file a complaint with the Practice and/or to the Secretary of HHS, or their
designee. If you wish to file a complaint with the Practice, please contact Jennifer Coburn.

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You may also file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200
Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/.

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The Practice will not take any adverse action against you as a result of your filing of a complaint.

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CONTACT INFORMATION

If you have any questions on the Practice’s privacy practices or for clarification on anything contained within the Notice, please contact:

 

 

Coburn's Pharmacy, LLC

Jennifer Coburn

101 South Austin St.
Bremond, TX 76629

(254) 746-7845