THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED OR DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

In accordance with the requirements for the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), Custom Rx is required to inform you of its practices in relation to the protected health information that it maintains about you. HIPAA mandates minimum standards that a covered entity such as Custom Rx must maintain in relation to your protected health information. This Notice of Privacy Practices is being provided to help you understand how Custom Rx meets these minimum standards. It is also meant to inform you of the ways that Custom Rx may use the personal information it collects about you and how it may disclose that information.
UNDERSTANDING YOUR PROTECTED HEALTH INFORMATION
When you receive care from a healthcare provider, a record of that treatment is made. This record will typically contain information on your diagnosis, treatment, and future plan of treatment and is often collectively referred to as your medical record. This medical record includes protected health information and lays the foundation for determining your plan of care and treatment and allows for a successful means of communication between all healthcare professionals that contribute to your care.

HIPAA protects information found in your medical record from disclosure without your authorization. The information protected by HIPAA includes:

1. Any information related to your past, present or future physical or mental health;
2. The past, present or future payment for health services you have received;
3. The specific care that you have received, are receiving or will receive;
4. Any information that identifies you as the individual receiving the care; and
5. Any information that someone could reasonably use to identify you as receiving the care. This information is referred to as protected health information (PHI) throughout this Notice.

USES AND DISCLOSURES OF PHI THAT MAY BE MADE WITHOUT YOUR AUTHORIZATION
TREATMENT, PAYMENT AND HEALTHCARE OPERATIONS

As a Covered Entity, Custom Rx is required to inform you of how it may use your protected health information. In providing treatment to you, Custom Rx will use your protected health information for the purposes of treatment, payment, and healthcare operations.

1. Treatment – As it pertains to Custom Rx, treatment means providing to you drugs, medications, supplies and durable medical equipment services as ordered by your physician. Treatment also includes coordination and consultation with you, your physician and other health care providers. As Custom Rx provides these services to you, information obtained during this process will be recorded in your medical record. Custom Rx will use this information, in coordination with your physician, to determine the best course of treatment for you.
2. Payment – Payment purposes consist of activities required to obtain reimbursement from your insurance carrier for the services ordered by your physician and provided to you by Custom Rx. This includes, but is not limited to, eligibility determination, precertification, billing and collection activities, obtaining documentation required by your insurer, and when applicable, disclosure of limited information to consumer reporting agencies. Your Protected Health Information may be disclosed to your plan sponsor, one or several intermediaries employed by your plan sponsor including but not limited to insurers, pharmacy benefits managers, claims administrators and computer switching companies. However, if you pay out of pocket for your services and make a specific request that Custom Rx not send information to your insurance carrier for those services, Custom Rx will not send that information to your insurance carrier except under certain circumstances.
3. Healthcare operations – Operations can include, but are not limited to, review of your protected health information by members of Custom Rx staff to ensure compliance with all federal and state regulations. This information will then be utilized to continually improve the quality and effectiveness of the services provided to you by Custom Rx. Healthcare Operations also include Custom Rx’s business management and general administrative activities including quality assessment and improvement, provider review and training, underwriting activities, reviews and compliance activities, and planning and development. When Custom Rx contracts with other businesses to do specific tasks for it, Custom Rx shares your protected health information related to those tasks. When Custom Rx does this, the business agrees in the contract to protect your health information and use and disclose such information only to the extent Custom Rx would be able to do so. These businesses are called Business Associates.
4. There are a limited number of other uses and disclosures of protected health information that do not require a specific authorization from you. Custom Rx may in the following circumstances disclose your protected health information.
5. Health-related communications – Custom Rx may contact you to provide refill reminders or information about treatment alternatives or other health-related benefits and services (e.g., health screenings, wellness events, inoculations, vaccinations) that may be of interest to you.
6. To discuss your treatment with other people involved with your care or payment for your care — Custom Rx may disclose to a member of your family, other relative, or a close personal friend, or any other person identified by you, the protected health information directly relevant to such person’s involvement with your care or payment related to your health care. Custom Rx may also disclose limited health information about you to notify local agencies (i.e. power, gas, phone company, and emergency medical services), in the event of an emergency (i.e. flood, tornados, etc.), of your need for life sustaining equipment or assistance in evacuation due to your medical condition. In addition we may use or disclose the Protected Health Information to notify, identify, or locate a member of your family, your personal representative, and any other person responsible for care of your location, general condition, or death. If you are incapacitated, there is an emergency, or you object to this use or disclosure, we will do in our judgment what is in your best interest regarding such disclosure and will disclose only the information that is directly relevant to the person’s involvement with your healthcare. We will also use our judgment and experience regarding your best interest in allowing people to pick-up filled prescriptions, or other similar forms of protected health information.
7. As required by law – Custom Rx may disclose protected health information to others as required by law.
8. To avert a serious threat to health or safety – Custom Rx may use and disclose your protected health information when necessary to prevent a serious threat to your health and safety or the health and safety of another person.
9. Public health risks — Custom Rx may disclose protected health information for certain public health activities and purposes which include the prevention or control of disease, injury or disability; to report births and deaths; to report child abuse or neglect; to report reactions to medications or problems with products; to notify people of recalls of devices or products; to notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition; or to notify the appropriate government authority if we believe you have been the victim of abuse, neglect, or domestic violence. If you agree, we can provide immunization information to schools.
10. Health oversight activities – Custom Rx may disclose protected health information to agencies authorized by law to conduct health oversight activities, including audits, investigations, licensing and similar activities.
11. Legal proceedings – Custom Rx may disclose your protected health information when we receive a court or administrative order. We may also disclose your protected health information if we get a subpoena, or another type of discovery request. If there is no court order or judicial subpoena, the attorneys requesting your protected health information must make an effort to tell you about the request for your protected health information.
12. Law enforcement — Custom Rx may disclose protected health information for law enforcement purposes. When a law enforcement official requests your protected health information, it may be disclosed in response to a court order, subpoena, warrant, summons, or similar process. It may also be disclosed to help law enforcement identify or locate a suspect, fugitive, material witness, or missing person. We may also disclose protected health information about the victim of a crime; about a death we believe may be the result of criminal conduct; about criminal conduct occurring on the premises of Custom Rx; or in an emergency to report a crime, the location of the crime, victims of the crime, or to identify the person who committed the crime.
13. Worker’s compensation – Custom Rx may release your protected health information for worker’s compensation or similar programs providing you benefits for work-related injuries or illness.
14. Research – Under certain circumstances, we may use and disclose your protected health information for medical research. All research projects, however, are subject to a special approval process. Before we use or disclose your health information for research, the project will have been approved.
15. Organ and tissue donation – Custom Rx may use or disclose your protected health information to an organ donation bank or to other organizations that handle organ procurement to assist with organ or tissue donation and transplantation.
16. Military and veterans – The protected health information of members of the United States Armed Forces and members of a foreign military authority may be disclosed as required by military command authorities.
17. National security and intelligence activities – When authorized by law, Custom Rx may disclose your protected health information to certain federal officials for intelligence, counterintelligence, and other national security activities.
18. Protective services for the President and others – Custom Rx may disclose your protected health information to certain federal officials so they may provide protection to the President, other persons, or foreign heads of state, or to conduct special investigations.
19. Coroners, medical examiners, and funeral directors – Custom Rx may disclose protected health information to a coroner or medical examiner to assist in the identification of a deceased person or to determine the cause of death, and to funeral directors to assist them with carrying out their duties.
20. Inmates or persons in custody – If you are or become an inmate of a correctional institution or under the custody of a law enforcement official, we may release your protected health information to the correctional institution or a law enforcement official when it is necessary for the institution to provide you with health care, when it is necessary to protect your health and safety or the health and safety of others, or when it is necessary for the safety and security of the correctional institution.

OTHER USES AND DISCLOSURES

1. Most uses and disclosures of psychotherapy notes (to the extent maintained by Custom Rx), uses and disclosures for marketing purposes, including subsidized treatment communications, and uses and disclosures that constitute a sale of protected health information require your written authorization.
2. Other uses and disclosures of your protected health information not covered by this Notice or the laws that apply to Custom Rx will be made only with your written authorization. You may revoke such authorization at any time, except to the extent Custom Rx has taken action in reliance on the authorization.

YOUR RIGHTS AS A PATIENT OF CUSTOM RX

In accordance with HIPAA you have the following rights in relation to your protected health information.

1. Right to a restriction — You may request, in writing, additional restrictions to the use or disclosure of your protected health information. To exercise this right, you should contact the Privacy Officer because you must complete a specific form to provide us with the information that we need to process your request. If you self-pay for a service and do not want your health information to go to your insurance carrier, we will not send the information, unless it has already been sent, you do not complete payment, or there is another specific reason we cannot accept the request. For example, if the law requires Custom Rx to bill your insurance carrier (e.g., a governmental payor), we cannot accept your request. Custom Rx does not have to agree to any other restriction. If we have previously agreed to another type of restriction, we may end that restriction. If we end a restriction, we will inform you in writing.
2. Right to amend your records — You have the right to request amendments or corrections to your medical record. To exercise this right, you must contact the Privacy Officer to complete a specific form stating your reason for the request and other information that we need to process your request. We can refuse your request if we did not create the information, if the information is not part of the information we maintain, if the information if part of information that you were denied access to, or if the information is accurate and complete as written. You will be notified in writing if your request if refused and you will be provided an opportunity to have your request included in your protected health information.
3. Right to obtain the Notice of Privacy Practices — You have the right to obtain a copy of this Notice of Privacy Practices. You may request a copy from the Privacy Officer or you may go to our website at www.CustomRx.net.
4. Right to access — You have the right of access to inspect and obtain a copy of your medical record, subject to certain limitations. To exercise this right, you should contact the Privacy Officer because you must complete a specific form so we have the information we need to process your request. If we maintain your information in an electronic format, you have the right to request that your information be provided in an electronic format. We will make every effort to provide access to your protected health information in the form or format you request, if it is readily producible in such form or format. Or you can receive your records in a paper copy. You may also direct that your protected health information be sent in an electronic format to another individual. You may be charged a reasonable fee for access. We can refuse access under certain circumstances. If we refuse access, Custom Rx will tell you in writing and in some circumstances you may ask that a neutral person review the refusal.
5. Right to accounting — You have the right to obtain an accounting of disclosures of your medical record for purposes other than treatment, payment, healthcare operations, and disclosures to you, your caregivers specified by you, for notifications or as otherwise excluded by law. To exercise this right, you should contact the Privacy Officer. There are specific time limits on such requests. You have the right to one accounting per year at no cost.
6. Right to communication accommodation — You have the right to request communications of your medical record by alternative means (i.e. electronically) or at alternative locations. If you choose to receive communications from Custom Rx via e-mail, those may not be a secure means of communication and your protected health information may be intercepted by an unauthorized third party. To exercise this right, you should contact the Privacy Officer and complete the appropriate form.
7. Right to receive notification of breach – You have the right to be notified if we determine that there has been a breach of your protected health information.

Right to file a complaint – If you believe your privacy rights as described in this Notice have been violated with our Privacy Officer or with the U.S. Department of Health & Human Services – Office for Civil Rights at following addresses:

Custom Rx, LLC
Attention: Privacy Officer
3510 North Ridge Rd., Ste 900
Wichita, KS 67205
316-721-2626

or

U.S. Department of Health & Human Services The Office of Civil Rights 3510 North Ridge Rd., Ste 900
Regional Office at Kansas City 601 East 12th Street Room 353
Kansas City, MO 64106 816-426-7277 (phone) 800-368-1019 816-426-3686 (fax)

RESPONSIBILITIES OF CUSTOM RX

In accordance with HIPAA, Custom Rx is required to:

1. Maintain the confidentiality of your protected health information.
2. Provide you with notice of our legal obligations and privacy practices regarding information we may accumulate about you and is obligated to abide by the terms of this notice.
3. Notify you if it is unable to agree to a requested restriction, and make every effort to accommodate reasonable requests for communication of health information by alternative means.
4. Post its Notice of Privacy Practices on its website at www.CustomRx.net.

Please be advised that in addition to these responsibilities, Custom Rx reserves the right to change the terms of its Notice of Privacy Practices and make those changes applicable to all protected health information maintained at the time. You may receive a copy of this notice by contacting us as outlined above or upon the receipt of pharmacy care services.

Effective Date: This Notice is effective as of September 23, 2013.