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

The pharmacy is required by law to maintain the privacy of Protected Health Information (“PHI”) and to provide to individuals with notice of our legal duties and privacy practices with respect to PHI. PHI is information that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services, the provision of health care products and services to you or payment for such services.

References to “Jersey Shore Pharmacy®”, “we,” “us,” and “our” include Jersey Shore Pharmacy® and the members of its affiliated covered entity. An affiliated covered entity is defined as a group of organizations under common ownership or control who designate themselves as a single affiliated covered entity for purposes of compliance with the Health Insurance Portability and Accountability Act (“HIPAA”). For a list of the members of the affiliated covered entity please contact our privacy officer.

Our organization is dedicated to maintaining the privacy of your identifiable health information and therefore all employees and members are all bound to follow the terms of this Notice of Privacy Practices (“Notice”). This means that by law we are required to maintain the confidentiality of Protected Health information that identifies you. This Notice describes how we may use and disclose PHI to carry out treatment, payment or health care operations and for other specified purposes that are permitted or required by law. This Notice also describes your rights with respect to PHI about you.

We reserve the right to change our practices and this Notice and to make the new Notice effective for all PHI we maintain. The potential revised and updated Notice is available upon request through our privacy officer.

To summarize, this notice provides you with the following important information:

• How we may use and disclose your Protected Health Information

• Your privacy rights in you Protected Health Information

• Our obligations concerning the use and disclosure of your Protected Health Information

• How we may use and disclose your Protected Health Information

The following categories describe different ways that we may use and disclose your Protected Health Information except where prohibited by federal or state laws that require special privacy protections. Not every permissible use or disclosure will be listed in the Notice. Some types of Protected Health Information, such as genetic information, alcohol and/or substance abuse records, HIV information, and mental health records may be subject to different confidentiality protections under appropriate state or federal law and we will abide by these special protections. These categories include examples of such uses or disclosures for each category. For additional information about special state laws, please feel free to contact our privacy officer.

Treatment. Our pharmacy may use your PHI to provide and coordinate the treatment, medications and services you receive. For example, our pharmacy may disclose PHI to pharmacists, prescribers, nurses, technicians and other professionals involved in your care in order to help us optimize your treatment.

Payment. Our pharmacy may use your PHI in order to bill and collect payment for the services and items we provide to you and for other payment activities related to the services that we provide. For example, our pharmacy may contact your insurer, pharmacy benefit manager, or other third-party payer to determine to what degree it will pay for health care related costs. By doing so we will be able to determine the cost of your co-payment and prescription. The information that is transmitted to your payer and accounts receivable department may include information that identifies you, as well as information about the services that were provided to you including the medications that you are being prescribed. Our pharmacy may disclose your PHI to other health care providers or HIPAA compliant covered entities for payment activities.

Health Care Operations. Our pharmacy may use and disclose your PHI to support our business activities. These activities include but are not limited to review and assessment of the quality of the services and products we provide you in addition to the outcomes of your therapy. Our pharmacy may disclose your PHI to attorneys and auditors dispatched by the government and/or payers. We may also disclose and use your PHI to monitor the performance of our staff and employees, including the health care professionals employed by our organization. Interns and students may also use your PHI for educational purposes.

We may also disclose your PHI to other HIPAA covered entities that have provided services to you in order to improve their quality and effectiveness. All disclosed PHI will be to entities that have had a relationship with you and pertains to that relationship. In some cases your information will be deidentified, meaning all your personal information will be removed so that the information transmitted cannot identify you.

In addition to the categories above, we may also use and disclose your Protected Health Information (“PHI”) without your prior authorization for the following purposes:

Business Associates. Our pharmacy may contract you with third parties to perform certain services. These services are delegated to contractors and include but are not limited to billing services, copy services and/or consulting services. For example, we may provide PHI to a claims submission service that ensures that our claims are submitted in the appropriate form to the appropriate payers. To protect you, we require the business associate to appropriately protect your health information.

Communication with individuals involved in your care and payment for your care. Our pharmacy may disclose your PHI to family members, relatives, or other individuals responsible for your care and/or payment for your care. If a person has the authority by law to make health care decisions for you, we will generally regard that person as your “personal representative” and treat them the same way we would treat you with respect to your PHI.

Food and Drug Administration (“FDA”). Our pharmacy may disclose to persons under the jurisdiction of the FDA or the FDA, PHI relative to adverse events with respect to drugs, foods, supplements, products and product defects, or post-marketing surveillance information to enable project recalls, repairs, or replacement.

Refill reminders. Our pharmacy may contact you to provide refill reminders or communication with you about a prescription that is prescribed to you so long as any payment we receive for making the communication is reasonably related to our cost of making the communication.

Workers compensation. Our pharmacy may disclose your PHI as authorized by and as necessary to comply with laws relating to workers compensation or similar programs.

Public Health. Our pharmacy may disclose your PHI to public health or legal authorities charged with preventing or controlling disease, injury, or disability.

Law Enforcement. Our pharmacy may disclose your PHI for law enforcement purposes as required by law or in response to a valid subpoena or other legal process. For example, if law enforcement presents a valid subpoena or court order, limited information can be provided to them according to this Notice.

As required by law. Our pharmacy must disclose your PHI when required by law.

Health oversight activities. Our pharmacy may disclose your PHI to an oversight agency for activities authorized by law such as state boards of pharmacy and the U.S. Drug Enforcement Administration (“DEA”). These oversight activities include audits, investigations, and inspections, as necessary for our licensure and for the government to monitor the health care system, government programs and compliance with civil rights.

Judicial and administrative proceedings. If you are involved in a lawsuit or dispute, our pharmacy may disclose your PHI in response to a court administrative order. Our pharmacy may disclose your PHI in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if the efforts have been made by the requesting party to tell you about the request or to obtain an order protecting the requested PHI.

Notification. Our pharmacy may use or disclose your PHI to notify or assist in notifying a family member, personal representative or other individual involved in your care of information regarding you location and general condition.

Coroners, medical examiners and funeral directors. Our pharmacy may disclose you PHI to a coroner or medical examiner for identification purposes, determining cause of death or for other reasons authorized by law. Other personnel may use this information to perform their duties.

Correctional institution. If you are or become an inmate of a correctional institution, our pharmacy may disclose to the institution or its agents, your PHI for your health and the health and safety of others such as the public and other persons.

Military and veterans. If you are a member of the armed forces, our pharmacy may release your PHI as require by military command authorities.

To avert a serious threat to health or safety. Our pharmacy may use or disclose your PHI when necessary to prevent a serious threat to your health and safety or the health and safety of the public and other persons.

Victims of abuse, neglect or domestic violence. Our pharmacy may use or 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. Our pharmacy will only disclose information to the extent required by law, if you agree to the disclosure or if the disclosure is allowed by law and our pharmacy believes it is necessary to prevent serious harm to you or other persons, or the law enforcement or public official that is to receive your information represents it is necessary.

The pharmacy must receive your authorization before using or disclosing your Protected Health Information (“PHI”) for purposes other than those listed above or as other permitted or required by law:

Specific uses or disclosure notices. Our pharmacy will obtain your written authorization for the use or disclosure of psychotherapy notes, use or disclosure of PHI for marketing, and for the sale of PHI, except in limited circumstances where applicable law allows such uses or disclosure without your authorization.

Fundraising. Our pharmacy will use or disclose your PHI as permitted by applicable law, we may contact you to provide you with information about fundraising efforts for various disease-state programs or other related efforts

Other uses and disclosures of Protected Health Information. Our pharmacy will obtain your written authorization before using or disclosing your PHI for purposes other than those described in this Notice or otherwise permitted by law. You have the right to revoke an authorization in writing at any time. 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 the authorization.

The pharmacy offers you the right to object to any uses and disclosures listed below:

Family and friends involved in your care. Unless you object, we may disclose your PHI to a member of your family or an individual who guarantees or is otherwise responsible for payment for your care.

Your health information rights:

Obtain a paper copy of the Notice upon request. You may request a copy of this notice at any time. To obtain a paper copy of this Notice please contact us through our website, in person, on the phone or by mail to our pharmacy. If mailing please direct to our privacy officer. Some health care providers may retain copies of this Notice for your use and review.

Request a restriction on certain uses and disclosures of Protected Health Information. You have the right to request additional restrictions on our use or disclosure of your PHI that we maintain by sending a mailed formal request to our pharmacy’s privacy officer. Our pharmacy is not required to agree to accept your restrictions unless the disclosure is to a health plan for purposes of carrying out payment or health care operations and is not otherwise required by law and your PHI pertains solely to a health care item or service for which you or a person on your behalf has paid in full. In the event that we accept your request for PHI restrictions, we will abide as it is related to your PHI on a going forward basis.

Inspect and obtain a copy of your Protected Health Information. You have the right to access and inspect or obtain a copy of your PHI. Our pharmacy will maintain records containing your PHI, in the case that this record is in an electronic format, you have the right to request it in this format. To access or copy your PHI you are required to send or deliver a formal written request to our pharmacy’s privacy officer. You may ask us to send a copy of your PHI to other individuals or entities that you designate in writing. Our pharmacy can deny your request to inspect and copy in certain limited circumstances. In the case that you are denied access, you may request that the denial be reviewed.

Request an amendment of Protected Health Information. If you feel that PHI that has been maintained about you is incomplete or incorrect, you may request an amendment. To request an amendment, you must send or deliver a formal written request to our pharmacy’s privacy officer. If we deny your request for amendment, you have the right to file a statement of disagreement with the decision and we will provide you with reasons as to the denial of your request.

Receive an accounting of disclosures of Protected Health Information. You have the right to receive an accounting of certain disclosures we have made of your PHI for most purposes. These disclosures can be delivered to you or other individuals involved with your care. To request an accounting of disclosures of PHI you must submit a written request to our pharmacy’s privacy officer.

Request communications of Protected Health Information by alternative means or at alternative locations. You have the right to request that we communicate with you about health matters in a certain way or at an alternative location. For example, you may request that we contact you at a different residence, via e-mail or by other means. If you request an electronic means of communication we cannot guarantee the security and protection of your PHI. In order to receive alternative communications please submit a written request to our pharmacy’s privacy officer. Our pharmacy will make all attempts to reasonably accommodate your needs. In the case that communication via the means you request has failed, we will attempt to contact you via the information we have.

For more information or to report a problem:

If you have questions or would like additional information regarding our pharmacy’s privacy practices, you may contact us in person or by mail addressed to our pharmacy. Please direct all correspondence to our privacy officer. If you believe your privacy rights have been violated, you may submit a complaint via our complaint form by phone, mail or other means. There will be no retaliation for filing a complaint.

Right to change terms of this notice: We may change the terms of this Notice at any time. In the event our pharmacy changes this Notice, we may make the new notice terms effective for all your PHI that we maintain, including any information created or received prior to issuing the new notice. If we change this Notice, we will post the new notice for your access. If you would like to request a new notice upon revision, please communicate with our privacy officer.

PATIENT BILL OF RIGHTS

You and your property have the right to be treated with respect, consideration, and recognition of consumer dignity and individuality from every pharmacy employee and be free from mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of client/patient property;

• You have the right to be fully informed in advance about care/service to be provided, including the disciplines that furnish care and the frequency of visits, as well as any modifications to the plan of care and the scope of services that the organization will provide and specific limitations on those services;

• You have the right to be informed about and participate in any changes to your plan of care, including but not limited to the transfer of services to another health care provider or the termination of services;

• You have the right to be informed verbally and in writing about the charges that you will be responsible for from the care and services provided including expected payments from third party payers and charges that the client is responsible for;

• You have the right to receive accurate and easily understood information about your care and/or drug therapy from a pharmacist including but not limited to the proper use and storage of prescribed therapy and possible adverse side effects and interactions with other drugs, supplements, or foods;

• You have the right to access support and discuss issues related to your medication(s) or related services with personnel of the pharmacy;

• You have the right to request and receive complete and up-to-date information regarding your condition, treatment, alternative treatments, risk of treatment or care plans;

• You have the right to receive instructions on the procedure of a drug recall;

• You have the right to be informed of our limitations regarding your service and care as they affect you;

• You have the right to informed consent and refusal of services or treatment after the consequences of refusing treatment are fully presented to you;

• You have the right to choose a heath care provider and pharmacy provider and not be pressured or coerced into transferring your prescriptions to another pharmacy;

• You have the right to receive appropriate care without discrimination in accordance with prescriber’s orders;

• You have the right to confidentiality and privacy of all information contained in the patient record and of Protected Health Information in accordance to HIPAA;

• You have the right to have personal health information shared with the patient management program only in accordance with state and federal law;

• You have the right to be informed of any financial benefits when referred to an organization;

• You have the right to know how to access support from consumer advocates;

• You have the right to receive pharmacy health and safety information to be fully informed of consumers rights and responsibilities;

• You have the right to know about philosophy and characteristics of the patient management program;

• You have the right to identify the staff member of the program through proper identification and their job title, and to speak with a supervisor of the staff member if requested;

• You have the right to receive information about the patient management program;

• You have the right to receive administrative information regarding changes in or termination of the patient management program;

• You have the right to decline participation, revoke consent or disenroll at any point in time;

• You have the right to formulate an advanced directive, if applicable;

• You have the right to participate in the development and periodic revision of the plan of care;

• You have the right to refuse care or treatment after the consequences of refusing care or treatment are fully presented;

• You have the right to voice grievances/complaints regarding treatment or care, lack of respect of property or recommend changes in policy, personnel, or care/service without restraint, interference, coercion, discrimination, or reprisal as well as have grievances/complaints regarding treatment or care that is (or fails to be) furnished, or lack of respect. This information will be investigated and if you are dissatisfied with the resolution, you may call the State Board of Pharmacy;

• You have the right to be advised on the pharmacy’s policies and procedures regarding the disclosure of clinical records and the pharmacy’s privacy policy;

Consumer Responsibilities

• You have the responsibility to dial “911” whenever a life threatening medical emergency arises. Contact the appropriate health care provider for other medical needs;

• You have the responsibility to provide complete and accurate information regarding your present and past health history and billing information;

• You have the responsibility to notify the pharmacy of any changes in your status, including address, medical condition, insurance and billing information;

• You have the responsibility to assume payment responsibility for co-pays, co-insurance or services not covered by your third-party payer, except where not allowed by law

• You have the responsibility to not share your prescribed medication with anyone;

• You have the responsibility to participate in your plan of care, ask questions and be proactive about your treatment;

• You have the responsibility to notify the pharmacy when medication supply is running low so refill can be shipped to you promptly;

• You have the responsibility to notify your prescriber and the pharmacy with any adverse drug reactions and/or complications in relation to your therapy;

• You have the responsibility to notify your prescriber that you will be participating under the care of our pharmacy’s services;

• You have the responsibility to submit any forms that’s are necessary to participate in the program to the extent required by law;

• You have the responsibility to give accurate clinical and contact information and to notify the patient management program of changes in this information;

• You have the responsibility to notify your treating provider of his or her participation in the patient management program, if applicable;

MEDICARE DMEPOS SUPPLIER STANDARDS

Note: This is an abbreviated version of the supplier standards every Medicare DMEPOS supplier must meet in order to obtain and retain their billing privileges. These standards, in their entirety, are listed in 42 C.F.R. 424.57(c).

• A supplier must be in compliance with all applicable Federal and State licensure and regulatory requirements.

• A supplier must provide complete and accurate information on the DMEPOS supplier application. Any changes to this information must be reported to the National Supplier Clearinghouse within 30 days.

• A supplier must have an authorized individual (whose signature is binding) sign the enrollment application for billing privileges.

• A supplier must fill orders from its own inventory, or contract with other companies for the purchase of items necessary to fill orders. A supplier may not contract with any entity that is currently excluded from the Medicare program, any State health care programs, or any other Federal procurement or non-procurement programs.

• A supplier must advise beneficiaries that they may rent or purchase inexpensive or routinely purchased durable medical equipment, and of the purchase option for capped rental equipment.

• A supplier must notify beneficiaries of warranty coverage and honor all warranties under applicable State law, and repair or replace free of charge Medicare covered items that are under warranty.

• A supplier must maintain a physical facility on an appropriate site and must maintain a visible sign with posted hours of operation. The location must be accessible to the public and staffed during posted hours of business. The location must be at least 200 square feet and contain space for storing records.

• A supplier must permit CMS or its agents to conduct on-site inspections to ascertain the supplier’s compliance with these standards.

• A supplier must maintain a primary business telephone listed under the name of the business in a local directory or a toll free number available through directory assistance. The exclusive use of a beeper, answering machine, answering service or cell phone during posted business hours is prohibited.

• A supplier must have comprehensive liability insurance in the amount of at least $300,000 that covers both the supplier’s place of business and all customers and employees of the supplier. If the supplier manufactures its own items, this insurance must also cover product liability and completed operations.

• A supplier is prohibited from direct solicitation to Medicare beneficiaries. For complete details on this prohibition see 42 CFR 424.57 (c) (11).

• A supplier is responsible for delivery of and must instruct beneficiaries on the use of Medicare covered items, and maintain proof of delivery and beneficiary instruction.

• A supplier must answer questions and respond to complaints of beneficiaries, and maintain documentation of such contacts.

• A supplier must maintain and replace at no charge or repair cost either directly, or through a service contract with another company, any Medicare-covered items it has rented to beneficiaries.

• A supplier must accept returns of substandard (less than full quality for the particular item) or unsuitable items (inappropriate for the beneficiary at the time it was fitted and rented or sold) from beneficiaries.

• A supplier must disclose these standards to each beneficiary it supplies a Medicare-covered item.

• A supplier must disclose any person having ownership, financial, or control interest in the supplier.

• A supplier must not convey or reassign a supplier number; i.e., the supplier may not sell or allow another entity to use its Medicare billing number.

• A supplier must have a complaint resolution protocol established to address beneficiary complaints that relate to these standards. A record of these complaints must be maintained at the physical facility.

• Complaint records must include: the name, address, telephone number and health insurance claim number of the beneficiary, a summary of the complaint, and any actions taken to resolve it.

• A supplier must agree to furnish CMS any information required by the Medicare statute and regulations.

• All suppliers must be accredited by a CMS-approved accreditation organization in order to receive and retain a supplier billing number. The accreditation must indicate the specific products and services, for which the supplier is accredited in order for the supplier to receive payment for those specific products and services (except for certain exempt pharmaceuticals).

• All suppliers must notify their accreditation organization when a new DMEPOS location is opened.

• All supplier locations, whether owned or subcontracted, must meet the DMEPOS quality standards and be separately accredited in order to bill Medicare.

• All suppliers must disclose upon enrollment all products and services, including the addition of new product lines for which they are seeking accreditation.

• A supplier must meet the surety bond requirements specified in 42 CFR 424.57 (d).

• A supplier must obtain oxygen from a state-licensed oxygen supplier.

• A supplier must maintain ordering and referring documentation consistent with provisions found in 42 CFR 424.516(f).

• A supplier is prohibited from sharing a practice location with other Medicare providers and suppliers.

• A supplier must remain open to the public for a minimum of 30 hours with certain exceptions.

Our Pharmacy can provide information to consumers including but not limited to billing information, contact information for the pharmacy, tips on product selection, refilling instructions, proper order placement, access to drugs in an emergency, order delays, how to reach consumer advocates, drug substitutions, instructions for transferring drugs, evidence based information regarding drugs and conditions, drug recall procedures, drug disposal, adverse drug reactions, and how to report concerns or errors.

PHARMACY COMPLAINT POLICY

Jersey Shore Pharmacy® provides you with the highest level of customer service. In the event that you are dissatisfied with the company’s services you have the right to file a complaint.

To file a complaint or privacy violation you may contact our pharmacy via e-mail, phone, fax or mail. Within five (5) calendar days of receiving a complaint, we will notify you that the complaint has been received and is being investigated. Your complaint will be documented and filed for review with our Quality Management Committee. A staff member will work with you to determine what actions should be initiated to resolve the problem. Within fourteen (14) calendar days, you will receive written correspondence notifying you with the results of the investigation and steps taken to resolve the complaint. Upon receiving this correspondence, you have the right to appeal any resolutions if you find they did not meet your expectations. If your complaint cannot be resolved, the review will be passed on to the Quality Management Committee for their next meeting. All complaints will be held in the strictest confidence. Information including your name will be disseminated on a need-to-know-basis only.

If you feel that your privacy rights have been violated, please contact our Privacy Officer. In the event that the complaint resolution has not met your expectations you may file a complaint with the Secretary of Health and Human Services, Office of Civil Rights at http://www.hhs.gov/ocr/privacy/hipaa/complaints/ or:

Secretary of the US Department of Health and Human Services

200 Independence Avenue S.W.

Washington D.C. 20201

202.619.0257 or toll free 1.877.696.6775

If you find that your complaint has been inappropriately handled, you may also contact the following agency:

New Jersey Office of the Attorney General

Division of Consumer Affairs

Board of Pharmacy

124 Halsey Street, 6th, P.O. Box 45013

Newark, NJ 07101

Phone: 973.504.6450

CONTACT US

Jersey Shore Pharmacy

580 North Main Street

Barnegat, NJ 08005

Phone: (609) 660-1111

Fax: (609) 660-0101

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