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.

I. Who We Are

This Notice describes the privacy practices of MOMS Pharmacy, its pharmacists, and other personnel who provide services at the pharmacy (“we” or “us”).

II. Our Privacy Obligations

We are required by law to maintain the privacy of health information about you (“Protected Health Information”) and to provide you with this Notice of our legal duties and privacy practices with respect to your Protected Health Information. When we use or disclose your Protected Health Information, we are required to abide by the terms of this Notice (or other notice in effect at the time of the use or disclosure).

III. Uses and Disclosures Requiring Your Written Authorization
A. Use or Disclosure with Your Authorization. For any purpose other than the ones described below in Section III.B and Section IV, we only may use or disclose your Protected Health Information when you grant us your written authorization on our authorization form (“Your Authorization”). For instance, generally, we must obtain Your Authorization prior to using your Protected Health Information for marketing purposes. We can, however, communicate with you about products or services related to your treatment, for case management or care coordination purposes, or about alternative treatments, therapies, providers or care settings without your written authorization. In addition, we may market to you in a face-to-face encounter and give you promotional gifts of nominal value without obtaining Your Authorization.

B. Uses and Disclosures of Your Prescription Information, From Which a Knowledgeable Person May Infer Your HIV Status. This type of information will never be used or disclosed to any person without your specific written authorization, except to certain other persons who need to know such information in connection with your medical care, and, in certain limited circumstances, to public health or other government officials (as required by law), to persons specified in a special court order, or to insurers as necessary for payment. This special written authorization (“Your Special Authorization”) is a New York State approved form which is a separate document from Your Authorization. We also may use or disclose such information in order for us to conduct certain health care operations as described in Section IV.C below.

There is only one type of disclosure of your prescription information (from which a knowledgeable person may infer your HIV status) which is permitted with Your Authorization, as opposed to Your Special Authorization: disclosures to a third party payor for any reason other than obtaining payment for health care services related to you.

IV. Permissible Uses and Disclosures Without Your Written Authorization

Except as provided in Section III.B above, we may use and disclose your Protected Health Information without Your Authorization or Your Special Authorization for the following purposes:

A. Treatment. We may use and disclose your Protected Health Information to provide treatment and other services to you--for example, to dispense prescription medication or provide medication information to you. In addition, we may contact you to confirm a delivery address or provide information about other health-related benefits and services that may be of interest to you. We may also disclose Protected Health Information to other providers involved in your treatment, including other pharmacists and/or pharmacies in order to fill a prescription. However, if we are transferring your prescription information to (or accepting a transfer from) another pharmacy for the purposes of providing one authorized refill, we shall only do this with your express request and approval.
B. Payment. We may use and disclose your Protected Health Information to obtain payment for health care services that we provide to you--for example, disclosures to claim and obtain payment from Medicare, Medicaid, your health insurer, HMO, or other company or program that arranges or pays the cost of some or all of your health care (“Your Payor”) to verify that Your Payor will pay for the health care.
C. Health Care Operations. We may use and disclose your Protected Health Information for our health care operations, which include internal administration and planning and various activities that improve the quality and cost effectiveness of the care that we deliver to you. For example, we may use Protected Health Information to evaluate the quality and competence of our pharmacists and other health care workers. We may disclose Protected Health Information to certain employees who are involved with resolving any complaints you may have and ensuring that you are satisfied with our services.
We are permitted to use or disclose your Protected Health Information for the following purposes. However, we may never have reason to make some of these disclosures:
D. Disclosure to Relatives, Close Friends and Other Caregivers. We may disclose your Protected Health Information to a family member, other relative, a close personal friend or any other person identified by you when you are present for, or otherwise available prior to, the disclosure, if: (1) we obtain your agreement or provide you with the opportunity to object to the disclosure and you do not object; or (2) we reasonably infer that you do not object to the disclosure.
If you are not present for or unavailable prior to a disclosure (e.g., when we receive a telephone call from a family member or other caregiver), we may exercise our professional judgment to determine whether a disclosure is in your best interests. If we disclose information under such circumstances, we would disclose only information that is directly relevant to the person’s involvement with your care.
E. As Required by Law. We may use and disclose your Protected Health Information when required to do so by any applicable federal, state or local law.
F. Public Health Activities. We may disclose your Protected Health Information: (1) to report health information to public health authorities for the purpose of preventing or controlling disease, injury or disability; (2) to report child abuse and neglect to a government authority authorized by law to receive such reports; and (3) to report information about products under the jurisdiction of the U.S. Food and Drug Administration.
G. Victims of Abuse, Neglect or Domestic Violence. We may disclose your Protected Health Information if we reasonably believe you are a victim of abuse, neglect or domestic violence to a government authority authorized by law to receive reports of such abuse, neglect, or domestic violence.
H. Health Oversight Activities. We may disclose your Protected Health Information to an agency that oversees the health care system and is charged with responsibility for ensuring compliance with the rules of government health programs such as Medicare and Medicaid.
I. Judicial and Administrative Proceedings. We may disclose your Protected Health Information in the course of a judicial or administrative proceeding in response to a legal order or other lawful process.
J. Law Enforcement Officials. We may disclose your Protected Health Information to the police or other law enforcement officials as required by law or in compliance with a court order.
K. Health or Safety. We may use or disclose your Protected Health Information to prevent or lessen a serious and imminent threat to a person’s or the public’s health or safety.
L. Workers’ Compensation. We may disclose your Protected Health Information as authorized by and to the extent necessary to comply with state law relating to workers' compensation or other similar programs.
V. Your Individual Rights

A. For Further Information; Complaints. If you desire further information about your privacy rights, are concerned that we have violated your privacy rights or disagree with a decision that we made about access to your Protected Health Information, you may contact our Privacy Office. You may also file written complaints with the Director, Office of Civil Rights of the U.S. Department of Health and Human Services. Upon request, the Privacy Office will provide you with the correct address for the Director, or you may obtain this information from the Office for Civil Rights website (www.hhs.gov/ocr/regmail.html). We will not retaliate against you if you file a complaint with us or the Director.

B. Right to Request Additional Restrictions. You may request restrictions on our use and disclosure of your Protected Health Information (1) for treatment, payment and health care operations, (2) to individuals (such as a family member, other relative, close personal friend or any other person identified by you) involved with your care or with payment related to your care, or (3) to notify or assist in the notification of such individuals regarding your location and general condition. While we will consider all requests for additional restrictions carefully, we are not required to agree to a requested restriction. If you wish to request additional restrictions, please obtain a request form from our Privacy Office and submit the completed form to the Privacy Office. We will send you a written response.

C. Right to Receive Communications by Alternative Means or at Alternative Locations. You may request, and we will accommodate, any reasonable written request for you to receive your Protected Health Information by alternative means of communication or at alternative locations.

D. Right to Inspect and Copy Your Health Information. You may request access to your health record file and billing records maintained by us in order to inspect and request copies of the records. Under limited circumstances, we may deny you access to a portion of your records. If you desire access to your records, please obtain a record request form from the Privacy Office and submit the completed form to the Privacy Office. If you request copies, we will charge you a reasonable, cost-based fee for copies and postage, if you request that we mail the copies to you.

E. Revocation of Your Authorization. You may revoke your authorization, except to the extent that we have taken action in reliance upon it, by delivering a written revocation statement to the Privacy Office identified below. A form of Written Revocation is available from the Privacy Office.

F. Right to Amend Your Records. You have the right to request that we amend your Protected Health Information maintained in your health record file or billing records. If you desire to amend your records, please obtain an amendment request form from the Privacy Office and submit the completed form to the Privacy Office. We will comply with your request unless we believe that the information that would be amended is accurate and complete or other special circumstances apply.

G. Right to Receive An Accounting of Disclosures. Upon request, you may obtain an accounting of certain disclosures of your Protected Health Information made by us during any period of time prior to the date of your request provided such period does not exceed six years and does not apply to disclosures that occurred prior to April 14, 2003. If you request an accounting more than once during a twelve (12) month period, we will charge you a reasonable, cost-based fee for the accounting statement.

H. Right to Receive Paper Copy of this Notice. Upon request, you may obtain a paper copy of this Notice, even if you agreed to receive such notice electronically.

VI. Effective Date and Duration of This Notice

A. Effective Date. This Notice is effective on April 14, 2003.

B. Right to Change Terms of this Notice. We may change the terms of this Notice at any time. If we change this Notice, we may make the new notice terms effective for all your Protected Health Information that we maintain, including any information created or received prior to issuing the new notice. If we change this Notice, we will post the new notice in our waiting area and on our Internet site at www.momspharmacy.com. You also may obtain any new notice by contacting the Privacy Office.

VII. Privacy Office

You may contact the Privacy Office at: