This notice describes how medical information about you may be used and disclosed
and how you can get access to this information.

Introduction:

All of us at Brewerton Pharmacy value your relationship with us and we know that
respect for your privacy is the foundation of that relationship. We are committed to
protecting the privacy of your Protected Health Information (PHI) that is in our
possession and only using and disclosing your PHI as necessary to provide you with
health care products and services. PHI is any information that we possess, use, and
disclose that identifies you and relates to your past, current, or future physical and
mental health condition or illness and the health care products and services that have
been provided to you.

This notice has been created to help you understand our legal duties to protect your PHI
and how we may use and disclose your PHI for your care. We will mainly use and
disclose your PHI to provide treatment and services to you as well as obtaining payment
for them. The notice also describes the legal rights that you have related to your PHI
that we hold. If use and disclosure of your PHI is needed in a way not described by this
notice, we will obtain your written permission.

Your rights with respect to your PHI

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) provides you
with several rights related to your PHI which are summarized:

1. You have the right to receive this written Notice of Privacy Practices.
2. You have the right to request a limitation on our use and disclosure of your PHI but
we may not agree if it inhibits our ability to provide health care products and services to
you or if we are required to disclose under federal or state laws. Requests for limitation
must be submitted to our Pharmacy Privacy Officer.
3. You have the right to review or receive photocopies of our records that contain your
PHI. You can review the records at no charge during business hours or receive
photocopies for a fee plus shipping. If we cannot provide our records we will provide a
written explanation as to why.
4. You have the right to request changes in the content of your PHI in our records if
incomplete or inaccurate. We may not be able to agree if we no longer have the
records or the change makes your PHI to become inaccurate.
5. You have the right to request that we communicate with you about your PHI in a
confidential manner.
6. The have the right to obtain an accounting of some of our disclosures of your PHI
made after April 14, 2003. Disclosures for purpose of treatment, obtaining payment and
carrying out health care operations are not required to be included in the accounting.
7. You have the right to file a complaint if you believe we have violated your rights as
described above. You can file directly with us or with the US Department of Health &
Human Services (HHS).
WAYS THAT WE MAY USE AND DISCLOSE YOUR PHI
1. Treatment – which is the provision, coordination, or management of health care and
related services by one or more health care providers including that with a third party.
2. Payment – which is activity to obtain reimbursement for the health care products and
services that we provide to you, such as billing you directly or someone who pays for
your health care such as a family member or health insurance company.
3. Health care operations – are those activities necessary and related to our providing
of health care products and services to you.
4. Business associate (BA) – such as a health insurance company or company that
processes claims that we submit for payment. We will submit contracts to all BAs to
assure they will protect your PHI privacy.
5. Disclosures of your PHI not involving treatment, payment, and health care operations
may be necessary but will be related to providing treatment to you.
6. Communications with you may be necessary. We want to do whatever is necessary
to assist with maintaining your health. We routinely monitor your prescription
medications to help you use them properly. For example, we may contact you to
remind you that a refill of your medication is due or, in the event of a recall, we may
contact you to inform you of the recall.
7. We may disclose your PHI to federal and state agencies for a variety of purposes,
most of which are directed at monitoring health care quality and safety.
8. If you apply for and receive benefits from federal and state health care programs,
your PHI may be disclosed to those agencies. If you are employed by a business
carrying workers’ compensation and you are injured in a way that workers’
compensation covers your health care, it may be necessary to disclose your PHI to the
workers’ compensation plan.
9. There a number of federal and state laws that require health care providers to report
to various government agencies, matters related to public health. If your illness or
condition is of a nature that requires that it be reported, we will disclose your PHI to the
appropriate agency in order to comply with these laws. We may also disclose your PHI
to government agencies in other situations such as suspected domestic, child or elder
abuse or neglect.
10. A number of federal, state and local government agencies are charged with
enforcing health care and drug laws in relation to the services we may provide to you.
As a state licensed pharmacy, some agencies regulate our activities. If we are required
by federal or state laws or by court order, subpoena, or other legal mandate, to disclose
your PHI, we will do so.
11. Lawsuits and other legal disputes may involve your PHI. In the event that you are
involved in one of these, whether as a plaintiff or defendant, we will disclose your PHI
when required to comply with a court order, subpoena, discovery proceeding, deposition
or other mandate served upon us.
12. A variety of events could occur where we would use and disclose your PHI for your
benefit and to prevent or reduce the risk of harm to you such as an accident and you
are unconscious in an emergency room and the staff calls us for your PHI to assist in
your medical treatment. We may also disclose your PHI if necessary to protect the
health and safety of others.
13. We are legally required to disclose your PHI where necessary if it is in the interest
of national security.
14. We may disclose your PHI if you are a member of the armed services, active or
reserve, as required by the US Military.
15. There are also a variety of disclosures that we may make in accordance with
HIPAA. We may have to disclose if you are placed into the custody of a federal or state
correctional system. We may disclose your PHI for purposes of a research project or to
organizations that manage organ transplantation programs.
IF YOU HAVE QUESTIONS ABOUT WAYS THAT WE MAY USE AND DISCLOSE
YOUR PHI AS DESCRIBED ABOVE, PLEASE CONTACT OUR PHARMACY PRIVACY
OFFICER AT THE PHARMACY ADDRESS OR TELEPHONE NUMBER.
If a use and disclosure of your PHI is not contained in this Notice, then we will obtain
your written authorization before the use and disclosure. You have the right to refuse or
to revoke previous authorizations. We will provide a form that describes the proposed
use and disclosure.

Conclusion:

HIPAA requires that we give you this Notice and make a good faith effort to obtain your
written acknowledgement that you were given this notice. We appreciate your
cooperation in reviewing and signing for this Notice.

For further information, questions or complaints, please contact our Privacy Officer:

Stacy Martin at
Brewerton Pharmacy
9679 Brewerton Road
Brewerton, NY 13029
315-676-4441

Or you can contact the office of:
Health and Human Services (HHS)
Hubert H. Humphrey Building
200 Independence Avenue SW
Washington, DC 20201