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.

Proper Uses or Disclosures of Protected Health Information

Inland Compounding Pharmacy (ICP) may use or disclose Protected Health Information (PHI) for the providing of patient treatment, payment and other health care operations. These operations include, but are not limited to the following:

1. In the preparation of a formulation or filling of a prescription, the pharmacist would have communication with the prescriber regarding new prescription information, refill authorization, and prescription adjustments.
2. To verify and facilitate patient insurance coverage, the pharmacist would have communication with the insurance company and it’s agents.
3. To transfer to or from another pharmacy, per the patient’s request, the pharmacist would have communication with another pharmacist.
4. To transmit patient information to a third party, for claims processing, the pharmacist would have communication with the insurance company and it’s agents. At the present time ICP is not involved in any electronic claims transmissions. ICP provides the patient with a Universal Claim Form to be signed and sent to their insurance company.

Other Authorized Uses and Disclosures

ICP is allowed to make certain other uses and disclosures without the patient’s written authorization. These include, but are not limited to the following:

1. Disclosures of specific patient information to a public health official.
2. Specific patient information in response to a valid court order.

Patient Written Authorization

ICP will obtain from the patient, written authorization for any use or disclosure of PHI not described in this notice. Written authorization will be made by completing a “Patient Written Authorization Form” provided by ICP, and by proving at least one form of picture identification, i.e. driver’s licenses . The patient may revoke any written authorization at any time, with the submission of a request in writing.

All authorizations and revocations will become part of the patient’s record.

Marketing and Patient Contact

ICP may contact the patient in order to provide refill reminders, information on treatment alternatives, or other health-related benefits or services. To provide written approval to receive information from ICP in the form of e-mail, fax, or newsletter, please sign the “Receive Information” box below. ICP will not use or provide patient PHI to be used in any marketing or promotional programs.

Patients Right's

Patient’s Rights include:

1. The right to inspect and copy his or her PHI records.
2. The right to request an accounting of PHI disclosures not related to treatment, payment, or health care operations.
3. The right to request an amendment to his or her PHI record. For example the patient may want to provide, a signed copy of a recent laboratory result for use by the pharmacist, in his or her record.
4. The right to request additional privacy protections. For example, the patient may want to prevent certain family members from having access to their PHI. A phone call, followed up with a written request will implement such a request. The patient may revoke any written request at any time, with the submission of an additional request in writing. This request will become part of the patient’s record.
5. The right obtain a paper copy of the notice.
6. Please take notice– that ICP does not have to agree to the patient’s request.

ICP's Legal Duties

ICP’s legal duties include:

1. Maintain the privacy of the PHI.
2. Provide patients with a notice of its legal duties and privacy practices.
3. Abide by the terms of the notice.
4. Make revision notices available to patients.

Patient Registration Of A Complaint

The patient may register a complaint with the secretary of the U.S. Department of Health and Human Services or with ICP directly, if his or her privacy rights are violated by the pharmacy. See ICP contact information below. It is important to remember that it is your right to file a complaint and that the patient will not face retaliation for filing a complaint.

ICP Contact Information

ICP’s Privacy Officer is Gordon E. Mote, Ph.D., M.B.A. Please feel free to contact him, at (909) 478-3842 by phone, or 24747 Redlands Blvd., Suite F., Loma Linda, CA 92354, by mail, regarding further information about the pharmacy’s privacy policies or to register a complaint.

Effective Date of This Notice Of Privacy Practices

The Effective date of the Notice of Privacy Practices is April 14, 2003.