Customer Notice of Health Information Practice

Clark Professional Pharmacy

Prescription Compounding and Health Education Specialist

Established 1980

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF
PRIVACY PRACTICES FOR CLARK PROFESSIONAL PHARMACY

By responding below, I acknowledge that I have received a copy of the Notice of Privacy Practices issued by Clark Professional Pharmacy.

Clark Professional Pharmacy

Effective Date: 04-15-2003

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.

u Understanding Your Health Record/ Information

Each time you visit Clark Pharmacy and purchase a product, or one of your physicians contacts us concerning your prescription needs or history, a record is made of this encounter. Typically, this record contains medical information from your referring physician, a prescription history, as well as other information you provide to us. In this “Notice of Health Information Practices,” we shall refer to the information contained in your record as your “health information,” which term shall have the same meaning as “protected health information,” defined in the Health Insurance Portability and Accountability Act of 1996, as amended (“HIPAA”).

u Your Health Information Rights

Within the limits provided by federal and state law, you have the right to:

Request restrictions on certain uses and disclosures of your health information;

Receive confidential communications of your health information. You may request that we communicate with you about your health information by alternative means or at an alternative location;

Inspect and obtain a copy of your health information, except with regard to psychotherapy notes or information compiled in reasonable anticipation of certain civil, criminal or administrative proceedings;

Request an amendment to your health information that we have created, except with regard to those portions of your health information that you are precluded from inspecting and copying as set forth above;

Obtain an accounting of certain disclosures of your health information; and

Receive a paper copy of this Notice in addition to any electronic copy you may receive.

You may exercise any of the above rights by submitting a written signed letter, detailing your request and mailing or delivering the letter to our Pharmacy. However, we encourage you to call first so that we can help you be as specific as possible with your request. We will promptly provide you with any forms that need to be completed to process your request.

u Our Responsibilities

This Pharmacy is required by law to:

Maintain the privacy of your health information;

Provide you with this Notice of our legal duties and privacy practices with respect to health information we collect and maintain about you;

Abide by the terms of this Notice, currently in effect, and as amended from time to time;

Notify you if we are unable to honor your request to restrict a use or disclosure of, or to amend, your health information; and

Accommodate reasonable requests you may have to communicate your health information by alternative means or at alternative locations.

We reserve the right to change our privacy practices and to make the new provisions effective for all of your health information we already have, as well as any health information we receive or create in the future. Should our privacy practices change, we will post a copy of the revised Notice in our Pharmacy, which indicates the effective date of the amended Notice. You may request and obtain a copy of our Notice of Privacy Practices anytime you visit our office. If a use or disclosure of your health information is not permitted under law without a written authorization, we will not use or disclose your health information without that written authorization. You may at any time revoke a written authorization in writing, except to the extent that we have already taken action in reliance of your authorization.

u For More Information or to Report a Problem

If you would like additional information concerning this notice, or a detailed copy of our privacy policy, please call our Privacy Officer, Patrice Shook, CPhT. at 734-434-7333 Monday through Thursday between the hours of 10:00 am and 4:00 pm.

If you believe that we have violated any of your privacy rights, you may file a written complaint with, Patrice Shook, CPhT or mail your written complaint to Clark Professional Pharmacy, 3075 W. Clark Road, Ypsilanti, MI 48197. You may also file your complaint with the Secretary of Health and Human Services. There will be no penalty or retaliation for filing a complaint.

Clark Professional Pharmacy 3075 Clark Road, Ypsilanti MI 48197 (734)434-7333 (800)468-0481