NOTICE OF PRIVACY PRACTICES

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.

Madison Pharmacy is required to maintain the privacy of your Protected Health Information (“PHI”) and to provide you with a notice of our legal duties and privacy practices with respect to PHI. PHI is information about you, including basic demographic information, that my identify you and that relates to your past, present or future physical or mental health or condition and related health care services. This Notice of Privacy Practices (“Notice”) describes how we may use and disclose PHI about you to carry out treatment, payment or health care operations and for other specific purposes that are permitted or required by law. The Notice also describes your right with respect to PHI about you.

Madison Pharmacy is required to follow the terms of this Notice. We will not use or disclose PHI about out without your written authorization, except as described in this Notice. We reserve the right to change our practices and this Notice and to make the new Notice effective for all PHI we maintain. Upon request, we will provide a revised Notice to you.

Your Health Information Rights

You have the following rights with respect to PHI about you:

· Obtain a paper copy of the Notice upon request. You may request a copy of the Notice at any time. Even if you have agreed to receive the Notice electronically, you are still entitled to a paper copy. To obtain a paper copy, contact the Privacy Officer at 973-377-0075.

· Request a restriction on certain uses and disclosures of PHI. You have the right to request additional restrictions on our use or disclosure of PHI about you by sending a written request to the Privacy Officer. We are not required to agree to those restrictions.

· Inspect and obtain a copy of PHI. You have the right to access and copy PHI about you contained in a designated record set for as long as Madison Pharmacy maintains the PHIO. The “designated record set” usually will include prescription and billing records. To inspect or copy PHI about you, you must send a written request to the Privacy Officer. We may charge you a fee for the costs of copying, mailing, or other supplies that are necessary to grant your request (see State Rights Section.) we may deny your request to inspect and copy in certain limited circumstances. If you are denied access to PHI about you, you may request that the denial be reviewed.

· 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. You may request an amendment for us as long as we maintain the PHI. To request an amendment, you must send a written request to the Privacy Officer. In addition, you must include a reason that supports your request. In certain cases, we may deny your request for amendment. If we deny your request for amendment, you have the right to file a statement of disagreement with the decision and we give you a rebuttal to your statement.

· Receiving an accounting disclosures of PHI. You have the right to receive an accounting of the disclosures we have made of PHI about you after April 14, 2003 for most purposes other than treatment, payment, or health care operations. The accounting will exclude disclosures we have made directly to you, disclosures to friends or family members involved in your care, and disclosures for notification purposes. The right to receive an accounting is subject to certain other exceptions, restrictions, and limitations. To request an accounting, your must submit your request in writing to the Privacy Officer. Your request must specify the time period, but may not be longer than sic years. The first accounting you request within a 12 month period will be provided free of charge, but you may be charged for the cost of providing additional accountings. We will notify you of the cost for providing additional accountings. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time.

· Request communications of PHI by alternative means or at alternative locations. For instance, you may request that we contact you about medical matters only in writing or at a different residence of post office box. To request confidential communication of PHI about you, you must submit your request in writing to the Privacy Officer. Your request must state how or when you would like to be contacted. We will accommodate all reasonable requests.

· Revoke your consent to use or disclose PHI. You may revoke consent in writing at any time. Upon receipt of the written revocation, we will stop using or disclosing PHI about you, except to the extent that we have already taken action in reliance on consent. We may refuse to continue to treat a customer that revokes his or her consent.

Examples of How We May Use and Disclose PHI

The following categories describe and provide examples of different ways that we use and disclose PHI about you.

We will use PHI for treatment. Example: Information obtained by the pharmacist will be used to dispense prescription medications to you. We will document in your record information related to the medications dispensed to you and services provided to you.

We will use PHI for payment. Example: we will contact your insurer or pharmacy benefit manager to determine whether it will pay for your prescription and the amount of your copayment responsibility. We will bill you or a third-party payor for the cost of prescription medication dispensed to you. The information on or accompanying the bill may include information that identifies you, as well as the prescription you are taking.

We will use PHI for health care operations. Examples: Madison Pharmacy may use information in your health record to monitor the performance of the pharmacists providing treatment to you. This information will be used in an effort to continually improve the quality and effectiveness of the health care and service we provide.

We are likely to use or disclose PHI for the following purposes:

Business associates: there are some services provided by us through contracts with business associates. Examples include the analysis of prescription costs and their trends for groups and sub-groups of patient populations. When these services are contracted for, we may disclose PHI about you to our business associate so that they can perform the job we have asked them to do and bill you or your third-party payor for services rendered. To protect PHI about you, we require the business associate to appropriately safeguard the PHI.

Communication with individuals involved in your care or payment for your care: Health professionals such as pharmacists, using professional judgment, may disclose to a family member, other relative, close personal friend or any person you identify, PHI relevant to that person’s involvement in your care or payment related to you care.

Personal communications: We may contact you to provide refill reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you.

Food and Drug Administration (FDA): We may disclose to the FDA or its agents PHI relative to adverse events with respect to drugs, foods, supplements, and products and product defects, or post marketing surveillance information to enable product recalls, repairs, or replacements.

State rights-New Jersey

You have the following additional rights with respect to PHI under New Jersey State Law:

If you are a member of Prepaid Prescription Service Organization (enrollee), all information relating to the diagnosis or treatment of an enrollee or prospective enrollee obtained by a prepaid prescription service organization is confidential and may not without the consent of the enrollee or perspective enrolle [N.J. Stat. Ann x 26:2-107]
If you have a form of cancer, New Jersey maintains a cancer registry, with mandatory reporting requirements, for the purpose of recognizing, preventing, curing and controlling such diseases. [N.J. Stat. Ann. xx 26:2-105; 26:2-106.] reports made to the cancer registry are to be used only by the State Department of Health and other agencies designated by the Commissioner of Health, and may not be divulged or made public. [N.J. Stat. Ann. x 26:2-107.]
With respect to Genetic Information, an individual or individual’s representative, promptly upon request, may inspect, request correction of and obtain genetic information from the records of the individual. This provision does not apply in the case of a policy of life insurance or disability income insurance contract, which is governed by the provisions of the insurance title.
With respect to HIV/AIDS, the AIDS assistance Act is a comprehensive statutory scheme for identifying cases and preventing the spread of HIV/AIDS. [N.J. Stat. Ann xx 26:5C-1 through 26:5C-18] under the statue, a record containing identifying information about a person who has or is suspected of having AIDS/HIV is confidential and may not be disclosed without the prior written consent of the person except for the purposes authorized by the Act. [N.J. Stat. Ann. xx 26:5C-7; 25:5C-8.]
With respect to Venereal Disease, Under New Jersey law, no person may disclose the name or identity of another person known or suspected of having a venereal disease except to the person’s physician, to a health authority or, in limited circumstances, to a prosecuting officer or to the court. [N.J. Stat. Ann. x 26:4-41.] the affected person’s physician or the health authority may disclose this information “when and only when” disclosure is necessary to protect the health or welfare of the person, his family, or the public. [Id.] Documents, records or reports that contain identifying information may not be open to inspection except to the Department of Health (and in limited circumstances a prosecuting officer and the court). Hospital records containing this information may be reviewed in connection with any claim for compensation or damages for personal injury or death. [N.J. Stat. Ann x 26;4-41.]
With respect to Substance Abuse, the treatment records of patients are confidential and may be made available upon proper judicial order. [N.J. Stat. Ann. x 26:2B-20.]

Worker’s compensation: We may disclose PHI about you to the extent authorized by and to the extent necessary to comply with laws relating to worker’s compensation or other similar programs established by law.

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

Law enforcement: We may disclose PHI about you for law enforcement purposes as required by law or in response to a valid subpoena.

As required by law: We must disclose PHI about you when required to do so by law.

Health oversight activities: We may disclose PHI about you to an oversight agency for activities authorized by law. These oversight activities include audits, investigations, and inspections, as necessary for our livensure and for the government to monitor the health care system, government programs and compliance with civil rights laws.

Judicial and Administrative proceedings: If you are involved in a lawsuit or a dispute, we may disclose PHI about you in response to a court or administrative order. We may also disclose PHI about you in response to a subpoena, discovery requests, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the requests or to obtain an order protecting the requested PHI. We are permitted to use or disclose PHI about you for the following purposes:

Research: We may disclose PHI about you to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and establishes protocols to ensure the privacy of your information.

Coroners, medical examiners, and funeral directors: we may release PHI about you to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or to determine the cause of death. We may also disclose PHI to funeral directors consistent with applicable law to carry out their duties.

Organ or tissue procurement organizations: Consistent with applicable law we may disclose PHI about you to organ procurement organizations or other entities engage in the procurement, banking, or transplantation of organs for the purpose of tissue donation and transplant.

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 institutions or its agents PHI necessary for your health and the health and safety of others.

To avert a serious threat to health or safety: We may use and disclose PHI about you 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 military authority.

National security and intelligence activities: We may release PHI about you to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.

Protective services for the President and others: We may disclose PHI about you to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state or conduct special investigations.

Victims of abuse, neglect or domestic violence: We may disclose PHI about you to government authority, such as a social service or protective services agency, if we reasonably believe you are a victim of abuse, neglect, or domestic violence. We will only disclose this type of information to the extent required by law, if you agree to disclosure, or if the disclosure is allowed by law and we believe it is necessary and will not be used against you.

Other Uses and Disclosures of PHI

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

For More Information or to Report a Problem

If you have questions or would like additional information about Madison Pharmacy’s privacy practices, you may contact Frank Iannarone III. If you believe your privacy rights have been violated, you can file a complaint with Frank Iannarone III or with the Secretary of Health and Human Services. There will be no retaliation for filing a complaint.