Notice of Privacy Practices

(Effective April 14, 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.

Mike’s Family Pharmacy is required by law to maintain the privacy of Protected Health Information (“PHI”) and to provide individuals with notice of our legal duties and privacy practices with respect to PHI. PHI is information that may 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 to carry out treatment, payment or health care operations and for other specified purposes that are permitted or required by law. The Notice also describes your rights with respect to PHI about you.

Mike’s Family Pharmacy is required to follow the terms of this Notice. PHI about you will not be used or disclosed without your 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, a revised Notice will be provided to you.

Examples of How We May Use and Disclose PHI

Treatment Example: We will use information to dispense prescription medications to you. Information will be documented in your record set related to the medications dispensed to you and services provided to you. We may disclose your PHI to other health care providers involved with your treatment.

Payment Example: We will contact your insurer or pharmacy benefit manager to determine whether it will pay for your prescription and the amount of any co-payment. We will bill you or a third-party payor for the cost of prescription medications dispensed to you. The information on or accompanying the bill may include information that identifies you as well as the prescriptions you are taking.

Health care operations Example: We may use information in your health record to monitor the performance of pharmacy personnel providing treatment to you in order to improve the quality and effectiveness of health care services.

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

Business associates: There are some services provided to you by us through contracts with business associates. 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 others involved in your care or payment for your care. Health professionals such as pharmacists, using their 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 you care or payment related to your care. We will use our professional judgment and our experience with common practice to make reasonable inferences of your best interest in allowing a person to pick up prescriptions or other PHI.

Food and Drug Administration (FDA): We may disclose to the FDA, or persons under its jurisdiction, PHI relative to adverse events with respect to medical or medical-related products.

Worker’s compensation: We may disclose PHI about you as necessary to comply with current law.

Public health, law enforcement and legal compliance: As required by law, we may disclose PHI about you to public health authorities, for law enforcement purposes, or as otherwise required 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 licensure 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, discover request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about he request 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 established protocols to ensure the privacy of your information.

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

Coroners, medical examiners, and funeral directors: We may release PHI about you to a coroner, medical examiner, or funeral director consistent with applicable law to carry out their duties.

Notification: We may use or disclose PHI about you to notify or assist in notifying a family member, personal representative, or another person responsible for you care, your location, and your general condition.

Correctional institution: If you are or become an inmate of a correctional institution, we may disclose PHI to the institution or its agents when necessary for your health or 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.

National security, intelligence activities, and protective services for the President and others: We may release PHI about you to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law. 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 to conduct special investigations.

Victims of abuse, neglect, or domestic violence: We may disclose PHI about you to a government authority if we reasonably believe you are a victim of abuse, neglect, or domestic violence. We will disclose this type of information to the extent required by law under the following conditions: (1) you agree to the disclosure or (2) the disclosure is allowed by law and we believe it is necessary to prevent serious harm to you or someone else or (3) the law enforcement or public official that is to receive the information represents that it is necessary and will not be used against you.

Other Uses and Disclosure of PHI:

We 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 an 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.

Your Health Information Rights

Obtain a paper copy of this Notice upon request: You may download* a copy of this Notice or you may request a written copy of this Notice from Mike’s Family Pharmacy.

*The privacy statement will be downloaded as a PDF file. Adobe Acrobat required. Depending upon your browser, the downloaded file will open in a new window or be downloaded directly to your computer.

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 submitting a written request. We are not required to agree to those restrictions.

Inspect and obtain a copy of PHI: You have the right to access or get a copy of PHI about you contained in a designated record set, which includes prescription and billing records, for as long as Mike’s Family Pharmacy maintains the PHI. Requests to inspect or copy PHI must be submitted in writing. You can be charged for any associated costs to include staff time necessary to fulfill your request. Your request to inspect and copy PHI may be denied in certain limited circumstances. If you are denied access to PHI about you, you may request in writing 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 for as long as we maintain the PHI. The request for amendment must be made in writing and include reasons that support your request. We may deny your request. If we deny your request, you have the right to file a statement of disagreement with the decision and we may give a rebuttal to your statement.

Receive an accounting of 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 certain disclosures, such as disclosures made directly to you, disclosures you authorize, disclosures to friends or family members involved in your care, and disclosure for notification purposes. The right to receive an accounting is subject to certain other exceptions, restrictions, and limitations. You must submit requests in writing. Your request must specify the time period, but may not be longer than six 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 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 or post office box. You must submit this request in writing. Your written request must state how or where you would like to be contacted. We will accommodate all reasonable requests.

For More Information or to Report a Problem:

If you have questions or would like additional information about the Mike’s Family Pharmacy’s privacy practices, you may contact the Mike’s Family Privacy Officer by phone at (231) 894-8633 or in writing to Mike’s Family Pharmacy, Privacy Officer, 8718 Water Street, Suite A, Montague, MI, 49437. If you believe your privacy rights have been violated, you can file a complaint through Mike’s Family Pharmacy, with the Privacy Officer or with the Secretary of Health and Human Services. There will be no retaliation for filing a complaint.