PRIVACY POLICY

Please review, print, and return to AmeriPharm with your first order.

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.

We know that keeping your personal information private is important to you. That’s why AmeriPharm wants you to know how we protect the information you share with us.

• AmeriPharm maintains physical, electronic, and procedural safeguards that meet state and federal regulations. Access to patient information is limited only to people that need the information for authorized pharmacy purposes.
  
• AmeriPharm may disclose information when required by law in order to respond to a subpoena, prevent fraud or comply with an inquiry by a government agency.
  
• We never share your health information with outside parties for marketing purposes.
  
• We never share your health information with a family member unless a written consent has been signed and is on file with us.

Types of information AmeriPharm collects:

• Information requested on patient order forms including; names, addresses, credit card information, health conditions and allergies.
• Data pertaining to your prescription profile, such as: name of prescription medication, strength, dosing instructions, physician’s name.
• Information collected from your health care provider, such as: gender, height, weight, medical diagnosis. This information is needed in order for AmeriPharm pharmacists to utilize their clinical expertise while delivering the best quality of care and is consistent with the patient-doctor-pharmacist relationship.

AmeriPharm commitment to Privacy:

• Collect only the information we need to help us deliver pharmacy products and services.
• Prevent unauthorized access to your information, including through the Internet.
• Refuse to disclose your health information to parties other than AmeriPharm, for purposes of marketing.
  
• Refuse to sell your information to outside mailing list companies or telemarketers.AmeriPharm may contact you by phone to provide refill reminder, information on treatment alternatives, or other health-related benefits or services.

Individual Rights

Access - At any time that you need to you can request a copy your prescription history with AmeriPharm. To do this, simply write to us at AmeriPharm, PO Box 5736, Sioux Falls SD 57117-5736, be sure to sign and date the request.

Restriction -You have the right to request that we place additional restrictions on our use or disclosure of your medical information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency). Any agreement to additional restrictions must be in writing signed by a person authorized to make such an agreement on our behalf. Mail it to AmeriPharm, PO Box 5736, Sioux Falls SD 57117-5736.

Amendment -You have the right to request that we amend your medical information. Your request must be in writing, and it must explain why the information should be amended. We may deny your request if we did not create the information you want amended and the originator remains available or for certain other reasons.

Disclosure Accounting – You have the right to receive a list of instances in which we or our business associates disclosed your medical information for purposes other than treatment, payment, health care operations, as authorized by you, and for certain other activities, since April 14, 2003. We will provide you with the date on which we made the disclosure, the name of the person or entity to whom we disclosed your medical information, a description of the medical information we disclosed, the reason for the disclosure, and certain other information.

Privacy Violation – If you feel that your privacy rights have been violated you can write to our Privacy Officer. Please indicate what violation occurred and the date(s) of occurrence. Send this to AmeriPharm, Inc Privacy Officer PO Box 5736 Sioux Falls SD 57117-5736.

INDIVIDUAL’S SIGNATURE

I, __________________________________________________,
have had full opportunity to read and consider the contents of this authorization, and I understand that, by signing this form, I am confirming my authorization of the use and/or disclosure of my protected health information, as described in this form.

Signature: _____________________________________

Date: ___________________________

If this authorization is signed by a personal representative on behalf of the individual, complete the following:

Personal Representative’s Name: _______________________________________________

Relationship to Individual: ____________________________________________________

Send completed and signed form to: OR MAIL IN WITH NEXT ORDER

AmeriPharm, Inc
PO Box 5736
Sioux Falls SD 57117-5736