RAYS PHARMACY & WELLNESS CENTERS
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.

Rays Pharmacy & Wellness Centers (‘the Pharmacy’) is required by law to maintain the privacy of protected health information and to provide individuals with this Notice of our legal duties and privacy practices with respect to protected health information. This Notice is being given to you to comply with the requirements of the privacy rules issued under the Health Insurance Portability and Accountability Act (‘the HIPAA Privacy Rules’).

OUR COMMITMENT TO YOUR PRIVACY

Rays Pharmacy & Wellness Centers is committed to safeguarding the privacy of your health information. We will comply with all applicable federal and state laws as to the privacy and confidentiality of your health information.

WHO SHOULD READ THIS NOTICE?

You should read this Notice if you are a customer of Rays Clocktower Plaza Pharmacy or if you might become a customer.

WHAT IS PROTECTED HEALTH INFORMATION?

Your protected health information (‘PHI’) is information that may identify you and that has to do with your past, present, or future physical or mental health or condition; the providing of health care to you; or the past, present, or future payment for health care provided to you.

WHO IS COVERED BY THIS NOTICE?

The terms ‘we’ or ‘our’ in this Notice refer to Rays Pharmacy & Wellness Centers.

WHAT INFORMATION IS IN THIS NOTICE?

This Notice describes your rights as to your PHI. This Notice also describes how we may use and disclose your PHI to carry out treatment, payment, health care operations, and for other specified purposes that are permitted or required by law. We are required to comply with the terms of this Notice. We will not use or disclose your PHI without your written authorization, except as described in this Notice.

WHAT RIGHTS DO YOU HAVE AS TO YOUR HEALTH INFORMATION?

To protect your privacy, you have been given the following rights as to your PHI:

Right to inspect and copy your PHI. You have the right to inspect and copy your PHI that is contained in a designated record set for as long as we maintain that PHI. The designated record set will usually include prescription and billing records. To inspect or copy your PHI, you must send a written request to: Chief & Rays General Office, Attn: Pharmacy Privacy Officer, P. O. Box 128, Defiance, OH 43512. We may charge you a fee for the costs of copying, postage, and supplies that are necessary to fulfill your request. In certain limited circumstances, we may deny your request to inspect and copy. If you are denied access to your PHI, you will be given written notice, and in most cases, you may request a review of that denial.

Right to request an amendment of your PHI. If you believe that the PHI we maintain about you is incomplete or incorrect, you may request that we amend it. You may request an amendment for as long as we maintain the PHI. To request an amendment, you must send a written request to Chief & Rays General Office, Attn: Pharmacy Privacy Officer, P. O. Box 128, Defiance, OH 43512. You must include a reason for 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 may give a rebuttal to your statement.

Right to receive an accounting of disclosures of your PHI. You have the right to receive an accounting of any disclosures of your PHI that we make 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 that you authorize, disclosures to friends or family members involved in your care, disclosures made by us in our notifications to you or to those involved in your care, and disclosures made before April 14, 2003. The right to receive an accounting is subject to certain other exceptions, restrictions, and limitations. To request an accounting, you must submit a request in writing to Chief & Rays General Office, Attn: Pharmacy Privacy Officer, P. O. Box 128, Defiance, OH 43512. Your request must specify the time period to be covered by the accounting, but your request may not cover disclosures made before April 14, 2003, or the date which is six years before your request, whichever is later. 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 any cost for an accounting, and you may choose to withdraw or modify your request at that time.

Right to request confidential communications. You have the right to request that we communicate your PHI to you by alternative means or to an alternative location. To request an amendment, you must send a written request to Chief & Rays General Office, Attn: Pharmacy Privacy Officer, P. O. Box 128, Defiance, OH 43512. We will accommodate any such request if it is reasonable.

Right to request a restriction on certain uses and disclosures of PHI. You have the right to request restrictions on our use or disclosure of your PHI for purposes of treatment, payment, or health care operations or to family members or other persons involved in, or responsible for, your health care. To request such a restriction, you must send a written request to Chief & Rays General Office, Attn: Pharmacy Privacy Officer, P. O. Box 128, Defiance, OH 43512. We are not required to agree to a restriction you request, but if we do agree, we will comply with that restriction unless that restriction would prevent you from receiving emergency medical treatment.

Right to obtain a paper copy of this Notice upon request. You may request a copy of this Notice at any time. Even if you have agreed to receive this Notice electronically, you are still entitled to a paper copy. To obtain a paper copy, you may ask for one at the Pharmacy or contact Chief & Rays General Office, Attn: Pharmacy Privacy Officer, P. O. Box 128, Defiance, OH 43512.

HOW MAY WE USE OR DISCLOSE YOUR HEALTH INFORMATION?

We have listed below descriptions and examples of the ways in which we may use or disclose your PHI. We will not use or disclose your PHI any more than is necessary to accomplish the purpose of that use or disclosure.

To provide pharmacy services to you, we must use and disclose your PHI as follows:

We will use PHI for your treatment. Example: Your PHI will be used by the pharmacist to dispense prescription medications to you. We will keep records having to do with the medications we dispense to you and services we provide to you.

We will use PHI to obtain payment. Example: We will contact your insurer or pharmacy benefit manager to determine whether it will pay for your prescription and to determine the amount of your 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 medications you are taking.

We will use PHI for health care operations. Health care operations include carrying out activities to improve the quality of our services; training our employees; reviewing the performance of our employees; obtaining legal services; auditing our financial statements; doing planning and development for our business; selling or buying prescription records; and managing the Pharmacy. Example: We 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 services we provide to you.

We may also use or disclose your PHI for the following purposes, but only to the extent allowed under the HIPAA Privacy Rules:

Business associates. To provide services to you, we need the help of outside business associates, such as prescription-processing software providers; third-party billing and reconciliation services; electronic data switching services; store security services; our auditors; our lawyers; the operators of franchised supermarkets in which our pharmacies may be located; and temporary-employee services that provide relief pharmacists. We may disclose your PHI to our business associates so they can perform the services we have asked them to do. We will require each of our business associates to appropriately safeguard your PHI.

Health-related communications. We may use or disclose your PHI for communications with you that have to do with your treatment or your health. For example, we may get in touch with you to give you refill reminders; to give you information about treatment alternatives or other health-related benefits, products, or services that may be of interest to you; to give you counseling about your treatment; to conduct drug-utilization reviews; or to discuss your health-care coverage or prescription benefits.

Communication with individuals involved in your care or payment for your care. Our 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 person¹s involvement in your care or payment related to your care. If you are a minor, you are responsible for informing us if you are legally authorized to consent to treatment to be provided by us and that the consent of a custodial parent or legal guardian to that treatment is not legally required.

As required by law. We must disclose your PHI when required to do so by law.

Health oversight activities. We may disclose your PHI to a health oversight agency, such as a state board of pharmacy, for oversight activities authorized by law. Those oversight activities might include audits; investigations; inspection; licensing or disciplinary actions; civil, administrative, or criminal proceedings; and other government activities to monitor or regulate the health care system, government programs, and compliance with civil rights laws.

Judicial and administrative proceedings. We may disclose your PHI in response to a court or administrative order. We also may disclose your PHI in response to a subpoena, discovery request, or other lawful process, but only if efforts have been made to notify you of the request or to obtain an order protecting the confidentiality of the requested PHI.

Workers compensation. We may disclose your PHI as authorized by, and as necessary to comply with, laws relating to workers¹ compensation or similar programs established by law.

Food and Drug Administration (FDA). We may disclose your PHI to the FDA, or persons under the jurisdiction of the FDA, for the purpose of reporting adverse events, defects, problems, or biological product deviations having to do with drugs, foods, diet supplements, and other products; tracking products; enabling the recall, repair, or replacement of products; or conducting post-marketing surveillance.

To prevent a serious threat to health or safety. When consistent with law and ethical standards, we may use and disclose your PHI when necessary to prevent a serious and immediate threat to your health or safety or to the health or safety of the public or another person.

Protecting public health. We may disclose your PHI to public health or legal authorities who are authorized by law to receive such information for the purpose of preventing or controlling disease, injury, disability, or child abuse or neglect.

Protecting victims of abuse, neglect, or domestic violence. We may disclose your PHI to a 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 disclose PHI for this reason only if the disclosure is required by law, if you agree to the disclosure, if we believe the disclosure is necessary to prevent serious harm to you or someone else, of if, in situations when you are unable to agree to the disclosure, the law enforcement or public official that is to receive the disclosure represents to us that the disclosure is necessary and will not be used against you.

Organ or tissue donations. If you donate, or agree to donate, any of your organs or tissue, we may disclose your PHI to an organization that procures, banks, or transplants organs or tissue to facilitate your donation or any transplants resulting from your donation.

Coroners, medical examiners, and funeral directors. If you die, we may release your PHI to a coroner or medical examiner for the purpose of identifying you; determining the cause of your death, or performing other duties allowed by law. If allowed by law, we may also disclose your PHI to funeral directors so they can carry out their duties.

Law enforcement. In the following circumstances, we may disclose your PHI for law enforcement purposes: as required by law; in response to a court order, subpoena, or other valid legal process; for the purpose of identifying or locating a suspect, fugitive, material witness, or missing person; if you are, or are suspected to be, a victim of a crime and you agree to the disclosure (unless your agreement cannot be obtained because of an emergency); if you are suspected of dying because of a crime; or if we believe the PHI being disclosed is evidence of a crime committed at the Pharmacy.

Medical research. We may disclose your PHI to medical researchers, but only if their research has been approved by an institutional review board or privacy board that has reviewed the research proposal and made sure that your privacy will be protected.

Correctional institution. If you are, or become, a inmate of a jail, prison, or other correctional institution, we may disclose PHI to the institution or its agents when necessary for your health or for the health or safety of others.

Military activities. If you are a member of the armed forces, we may disclose your PHI for activities that appropriate military command authorities believe are necessary for properly carrying out the military mission of the armed forces. We may also disclose PHI about foreign military personnel to their appropriate foreign military authority.

Medical research. We may disclose your PHI to medical researchers, but only if their research has been approved by an institutional review board or privacy board that has reviewed the research proposal and made sure that your privacy will be protected.

National security and intelligence activities. We may release your PHI to authorized federal officials for intelligence, counter-intelligence, and other national security activities authorized by law.

Protecting the President and others. We may disclose your PHI to authorized federal officials so they can protect the President of the United States, foreign heads of state, or other authorized persons designated by law or conduct investigations authorized by law.

NO OTHER USES OR DISCLOSURES WITHOUT YOUR AUTHORIZATION

We will not use or disclose your PHI in any way other than those listed above unless you authorize us to do so in writing. If you want to revoke your authorization, you may do so in writing at any time, but your revocation will only affect uses and disclosures of PHI that occur after we receive your revocation.

HOW DO YOU MAKE A COMPLAINT?

If you believe your privacy rights have been violated, you may file a complaint with us or the Secretary of Health and Human Services at the following addresses:

Chief & Rays General Office
Attn: Pharmacy Privacy Officer
P. O. Box 128
Defiance, OH 43512

-or-

Department of Health and Human Services
Office of Civil Rights
Room 509F HHH Building
Hubert H. Humphrey Building
200 Independence Ave. SW
Washington, DC 20201

Complaints must be in writing. You will not be penalized for filing a complaint.

WHERE CAN YOU GET MORE INFORMATION?

If you would like more information about the subjects covered in this Notice, please contact: Chief & Rays General Office, Attn: Pharmacy Privacy Officer, P. O. Box 128, Defiance, OH 43512

WHEN IS THIS NOTICE EFFECTIVE?

This Notice is effective as of April 14, 2003, and will remain in effect until we change it. We reserve the right to change our privacy practices and this Notice and to have those changes apply to all present or future PHI that we maintain, even PHI that was created or obtained before those changes went into effect. If we make changes to our privacy practices, we will revise this Notice, and if those changes are material, we will distribute the revised Notice. Any revised Notice will be posted.