NOTICE OF PRIVACY PRACTICES

Health Insurance Portability and Accountability Act (“HIPAA”) This notice describes how medical information about patients may be used and disclosed and how patients can get access to this information. PLEASE REVIEW THIS CAREFULLY.

HIPAA requires that Ye Olde Pharmacy describe to you how your “protected health information” will be used and how it will be disclosed in the course of doing business whether to carry out treatment, payment or health care operations or for disclosures that are required by law. Each will be discussed in detail below.

This Notice also describes your rights and Ye Olde Pharmacy's duties with respect to your protected health information.

WHAT IS YOUR “PROTECTED HEALTH INFORMATION”?

What is your “protected health information” (“PHI”)? Your “PHI” is information about you that may identify you, that is related to your past, present or future physical or mental health or condition and that is related health care services you receive. Your PHI also includes basic demographic information such as your name, address, phone number and other identifying information. Your PHI will include, as well, information you provide about drugs you are taking, medical conditions that you may have, and allergies and other matters which affect your health. Ye Olde Pharmacy maintains this information in its computer system.

TREATMENT, PAYMENT AND HEALTH CARE OPERATIONS

Ye Olde Pharmacy will use your PHI to treat you. For example your PHI will be used to dispense prescription medications. Ye Olde Pharmacy may disclose your PHI to your health care providers for the purpose of treatment. We will use your PHI to receive payment for products and services you obtain at CPBH. We may also contact your third party payor (such as insurer or pharmaceutical benefits manager) to determine whether your program will pay for your prescription or medical supplies. We may bill you and /or your third party payor for the cost of prescription medications dispensed to you; the information on an accompanying bill may include your identification as well as the prescriptions your are taking. We may also be required to use your PHI to carry out health care operations, such as monitoring the quality of pharmacist performance or, possibly, to train pharmacy personnel.

USES AND DISCLOSURES THAT ARE EITHER PERMITTED OR REQUIRED BY HIPAA REGULATIONS

Using their judgment as health care professionals, our pharmacists may disclose your PHI to a person you identify as being involved in your health care; this could be a family member, relative or close personal friend. In the course of our business, we also may form contacts with entities (“Business Associates”) to perform services for us. From time to time our Business Associates may assist in the processing and administration of insurance or other third party payor claims. For your protections, we require these Business Associates to safeguard your confidential PHI as rigorously as we do. We may also contact you to provide refill reminders, information about treatment alternatives and/or other health related benefits and services that you may find relevant or interesting.

OTHER REQUIRED OR PERMITTED DISCLOSURES

HIPAA requires us to provide you with examples of PHI disclosures that we are required to make under state or federal law; these include disclosures:

to the Food and Drug Administration (“FDA”) regarding adverse events which may arise from drugs, foods, supplements and other health products or we may be required to post notices of product recalls, repairs or replacements; to public health or legal authorities charged with preventing or controlling disease, injury or disability; to law enforcement agencies as required by law or in response to a valid subpoena or other legal process; to health oversight agencies/medical licensing for audits, investigations and/or inspections that are required by law which are either a part of Ye Olde Pharmacy's licensing process and procedures or to enable the government to monitor the health care delivery system; in response to a court order, administrative order, subpoena, discovery request or other lawful process by another person involved in a dispute involving a patient but only if efforts have been made to tell the patient about the request to obtain an order protecting the requested health care information; as authorized by and as necessary to comply with worker’s compensation laws or similar programs established by law; whenever required to do so by law; to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to insure the privacy of the patient’s information; to a coroner or other medical examiner when necessary, for example, to identify a deceased person or to determine a cause of death or to funeral directors under applicable law to enable them to carry out their lawful duties; to organ procurement organizations or other entities engaged in the procurement, banking or transplantation of organs for the purpose of tissue donation and transplant, as required by applicable law; to notify or assist in notifying a family member, personal representative or other person responsible for the patient’s care, of the patients’ location, or general condition; to a correctional institution or its agents, if a patient is or becomes an inmate of such institution when necessary for the patient’s health or the health and safety of others; when necessary to prevent a serious threat to the patient’s health and safety or to the health and safety of the public or another person; as required by law to military command authorities when the patient is a member of the armed forces as well as to appropriate military authority about foreign military personnel; to authorized federal officials for intelligence, counter intelligence and other national security activities required by law; to authorized federal officials so they may provide protection to the president , to other authorized persons or foreign heads of state or to conduct special investigations; to a government authority, such as a social service or protective services agency if Ye Olde Pharmacy reasonably believes a patient to be the victim of abuse, neglect or domestic violence but only to the extent required by law, if the patient agrees to the disclosure or if the disclosure is allowed by law and Ye Olde Pharmacy believes it is necessary to prevent serious harm to the patient or to someone else or the law enforcement or public official that is to receive the report represents that this is necessary and will not be used against the patient.

FURTHER PROTECTION

If, in the future, Ye Olde Pharmacy seeks to use your PHI for any reason other than those listed above, Ye Olde Pharmacy will obtain your written authorization before your PHI is used or disclosed. You have the right to revoke an Authorization in writing at any time. To do this, your revocation must be in writing; forms are available from us for this purpose. Completed and signed forms must be either left with a pharmacist at the pharmacy or mailed to John Jankowski at Ye Olde Pharmacy, N54 W6135 Mill Street, Cedarburg, WI 53012. Upon receipt of the written revocation, we will stop using or disclosing your PHI except to the extent that we have already taken action in reliance on your prior Authorization.

PATIENT’S RIGHTS

RESTRICTION REQUESTS

You have the right to request that we restrict the use or disclosure of your PHI in carrying out treatment, payment or health care operations. Such requests must be made to the Privacy Officer, John Jankowski at Ye Olde Pharmacy, N54 W6135 Mill Street, Cedarburg, WI 53012. PLEASE NOTE: we are not required to agree to the requested restrictions. If, however, we do agree to the requested restrictions, that agreement will be binding on us.

ALTERNATIVE MEANS OF COMMUNICATION

You also have the right to request that our communications with you concerning your health care and PHI be made by an alternative means or at alternative location. For example you can request that we communicate in some way other than by a mailing or telephone call to your. Your requests must be made in writing to the Privacy Officer, John Jankowski at Ye Olde Pharmacy, N54 W6135 Mill Street, Cedarburg, WI 53012. We will comply with your reasonable request.

ACCESS

You also have the right to inspect and obtain a copy of your PHI. You have the right to access and copy any protected information about your in your designated PHI record set for as long as we maintain your PHI. The designated record set usually will include prescription and billing records.

To receive a copy of your protected health information, you must send a written request to the Privacy Officer, John Jankowski at Ye Olde Pharmacy, N54 W6135 Mill Street, Cedarburg, WI 53012. Forms for making Access requests are available in our pharmacy. We may charge you a fee for the costs of copying, mailing or other supplies that are necessary to grant your request. We may also deny your request to inspect and copy in limited circumstances. If you are denied access to your protected health information, in most cases you may request that the denial be reviewed.

HEALTH CARE INFORMATION AMENDMENTS

If you feel that your PHI at CPBH is incomplete or incorrect, you may request that we amend it. You may request an Amendment for as long as we maintain protected health information. A request for an Amendment must be made in writing. Forms for making such requests are available at our pharmacy; they should be completed and sent to the Privacy Officer, John Jankowski at Ye Olde Pharmacy, N54 W6135 Mill Street, Cedarburg, WI 53012. You must include a reason that supports your request in certain cases. We may deny the request; if your request for Amendment is denied you have the right to file a “Statement of Disagreement” with the decision and we may give a rebuttal to your statement.

ACCOUNTING OF DISCLOSURES

For most purposes other than treatment, payment or health care operations, you have the right to receive an Accounting enumerating disclosures of your PHI that we have made on or after April 14, 2003. The Accounting will exclude disclosures we may have made directly to you, disclosures to designated friends or family members involved in your care and disclosures for those purposes you specifically authorized in writing. The right to receive an Accounting is subject to certain other exceptions, restrictions and limitations. A request for an accounting must be made in writing; forms are available in the pharmacy. Completed forms should be sent to the Privacy Officer, John Jankowski at Ye Olde Pharmacy, N54 W6135 Mill Street, Cedarburg, WI 53012. You must specify the time period of the requested accounting; it may not be longer than six (6) years. The first Accounting you request within a 12-month period will be provided free of charge but you will be charged for the cost of providing more than one Accounting within a 12 month period. We will notify you of the cost involved and you may choose to withdraw or modify the request at that time.

If you make any objections or complaints to Ye Olde Pharmacy, whether authorized by HIPAA or not, please be assured that they will be handled respectfully, professionally, promptly and “without retaliation” (a word we are required to use under HIPAA).

NOTICE OF PRIVACY PRACTICES

You have a right to receive a paper copy of this Notice from us upon request even if you have already received the Notice electronically (for example by e-mal or on the internet).

YE OLDE PHARMACY'S DUTIES

Ye Olde Phamracy takes its responsibility for maintaining your protected health information in confidence very seriously. We are required by law to maintain the privacy of your PHI and to provide you with a Notice of Privacy Practices that includes our legal duties with respect to protected health information. We are also required to abide by the terms of the Notice that is currently in effect.

Ye Olde Pharmacy reserves the right to change the terms of its Notice and to make the new Notice provisions effective for all protected health information that we maintain. When we make a change in our Notice, copies of the revised Notice will be available on requires in our pharmacy.

FOR MORE INFORMATION OR TO REPORT A PROBLEM

If you have questions or would like additional information about our privacy practices, you may contact the Privacy Office at (262) 375-0010 or by writing to the Privacy Officer, John Jankowski at Ye Olde Pharmacy, N54 W6135 Mill Street, Cedarburg, WI 53012. Forms for filing a written complaint to Ye Olde Pharmacy are available at our pharmacy. If you believe your privacy rights have been violated, you can file a complaint with the Privacy Office or with the Secretary of Health and Human Services. There will be no retaliation for filing a complaint.

EFFECTIVE DATE

This Notice of Privacy is effective April 14, 2003.