Billing Questions Billing Questions Name* Email* Message Health Depot Inc. Disclaimer No information provided to you by Health Depot is meant to diagnose a medical condition or serve as a substitute for the advice of your physician. If you or your family member has a medical emergency, please call 911. Health Depot believes in providing a quick and private way for our customers to communicate via the web. The information you provide will be treated confidentially and viewed only by our staff. Sometimes, questions may arise that may require a phone call from our staff to obtain additional information in completing your request. If we respond via email, it will be to the email address you provide. Patient Confidentiality and Security are extremely important at Health Depot, although constantly improving, internet security is not perfect. While Health Depot will never knowingly violate your confidentiality, we cannot guarantee the security of our response to you via internet e-mail; by clicking the "Accept" button you are giving Health Depot the right to respond to your via internet e-mail. Our Pharmacists Will Not Answer Questions Regarding: • Advice for diagnosis or treatment in the event of an injury or emergency. In such cases, please call a physician or 911. • Information regarding poisonings. For information, call the Arkansas Poison and Drug Information Center (APDIC) at 1-800-222-1222. • Information related to illegal or illicit drug use. Health Depot Inc. Notice of Privacy Practices September 23, 2013 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 understand that your medical information is personal. We are committed to protecting your medical information. Health Depot is required by law to maintain the privacy of your protected health information ("PHI"), to follow the terms of this Notice, and to give you this Notice of our legal duties and privacy practices concerning your health information. We must follow the terms of the current Notice. How Health Depot May Use or Disclose Your Health Information For Treatment: We may use your PHI to dispense prescriptions or medical products/services to you. We may disclose your PHI to treating physicians and other persons who are involved in your healthcare treatment. For Payment: We may use and disclose your PHI so that we can bill and collect payment from you, your insurance company or a third party. This may include conducting insurance eligibility checks with state Medicaid, Medicare, or other health plans, determining enrollment status, and providing information to entities that help us submit bills and collect amounts owed. For Health Care Operations: We may use and disclose your PHI for health care operations, which include activities necessary to provide health care services and ensure you receive quality customer care. For Prescription Refill Reminders and Health-Related Products and Services: We may use or disclose your PHI to: (1) provide you prescription refill reminders; (2) notify you of an expired prescription; (3) tell you about health-related products or services; (4) recommend possible treatment alternatives that may be of interest to you. Individuals Involved in Your Care or Payment for Your Care: We may disclose your PHI to a family member or friend who is involved in your medical care or payment for your care, provided you agree to this disclosure or we give you an opportunity to object to the disclosure. If you are unavailable or are unable to object, we will use our best judgment to decide whether this disclosure is in your best interest. As Required by Law: We will disclose your PHI when required to do so by federal, state or local law. To Avert a Serious Threat to Health or Safety: We may use and disclose your PHI when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. We may disclose your PHI for public health activities, such as those aimed at preventing or controlling disease, preventing injury, reporting reactions to medications or problems with products, recalling products, and reporting the abuse or neglect of children, elders and dependent adults. Any disclosure, however, would only be to someone able to help prevent the threat. For Disaster Relief: We may use and disclose your PHI to organizations for purposes of disaster relief efforts. For Health Oversight Activities: We may disclose PHI to a health oversight agency for activities authorized by law. These oversight activities, which are necessary for the government to monitor the health care system, include audits, investigations, inspections and licensure. For Lawsuits and Disputes: If you are involved in a lawsuit or dispute, we may disclose your PHI in response to a court or administrative order. We may also disclose your PHI in response to a subpoena, discovery request or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request (which may include written notice) or to obtain an order protecting the information requested. For Specialized Government Functions:We may disclose your PHI: (1) if you are a member of the armed forces, as required by military command authorities; (2) if you are an inmate or in custody, to a correctional institution or law enforcement official; (3) in response to a request from law enforcement, under certain conditions; (4) for national security reasons authorized by law; (5) to authorized federal officials to protect the President, other authorized persons or foreign heads of state. For Workers' Compensation: We may disclose your health information for workers' compensation or similar programs. For Incidental Disclosures at the Pharmacy Drive-Thru Window or In Store: When drive-thru windows are used a conversation with staff might be overheard by someone in or near the area. If you would like additional privacy, we suggest you conduct any transactions in the store. Conversations with staff in the store might be overheard by others near the area, if you would like additional privacy; a private consultation area is available. For Organ and Tissue Donation: We may also disclose your PHI to organ procurement or similar organizations for purposes of donation or transplant. For Coroners and Funeral Directors: Upon your death, we may release your PHI to a funeral home director, coroner, or medical examiner, consistent with applicable law to enable them to carry out their duties . For Personal Representatives: We may disclose your PHI to a person legally authorized to act on your behalf, such as a parent, legal guardian, administrator or executor of your estate, or other individual authorized under applicable law. For Marketing: With your authorization, we may use or disclose your PHI to our third-party agents, representatives, service providers and /or contractors to offer targeted marketing communications to you. For Sale of PHI: With your authorization, we may receive remuneration, financial or otherwise, directly or indirectly in exchange for your PHI. For Business Associates: We may share your PHI with certain business associates that perform services for us. We may disclose your PHI to a business associate so that the business associate can perform the job we have asked it to do and bill you or your third-party payer for services rendered. Federal law requires us to enter into business associate contracts to safeguard your PHI as required by law and Health Depot. Limitations on Uses and Disclosures of Your Health Information: Except as described in this Notice, we will not use or disclose your PHI without your authorization. If you do give us authorization to use or disclose your PHI, you may cancel your authorization in writing at any time. If you cancel your authorization, this will stop any further use or disclosure for the purposes covered by your authorization, except where we have already acted on your permission. We must also follow any state law that is stricter than federal HIPAA regulations. Notice of Breach: In the event of a security breach involving your PHI, a notice will be provided to you. You Have the Following Rights with Respect to Your Health Information in Our Records: You may request restrictions on the use or disclosure of your PHI for as long as we maintain the PHI for treatment, payment or health care operations, or when using or disclosing your PHI to someone who is involved in your care or the payment for your care, like a family member or friend. We are not required to agree to your request. If we agree, we will comply with your request except in certain emergency situations or as required by law. You may request restrictions on certain disclosure for as long as we maintain the PHI to your health plan for purposes of carrying out payment or health care operations regarding services paid for in full (out of pocket). You may inspect and receive a paper or electronic copy of your medical records, if readily producible for as long as we maintain the PHI. Usually, this includes prescription and billing records. We may charge you for the costs of responding to your request. We may deny your request, in which case, you may request the denial be reviewed. You may request we amend your health information for as long as we maintain the PHI if it is incorrect or incomplete. You must provide a reason that supports your request. We may deny your request if the health information is accurate and complete, or is not part of the health information kept by Health Depot. If we deny your request, you have the right to submit a statement of disagreement regarding any item in your record you believe is incomplete or incorrect. Your request will become part of your medical record. We will attach it to your records and include it when we make a disclosure of the item or statement you believe to be incomplete or incorrect. You may request an accounting of disclosures of your PHI for as long as we maintain the PHI. This is a list of the disclosures made of your health information, other than for treatment, payment or health care operations, and other exceptions allowed by law. Your request must specify a time period, which may not be longer than six years and may not include dates before April 14, 2003. You may request we contact you in a certain way at a certain location. For example, you may request we contact you only at work or at a different residence or post office box. Your written request must state how or where you wish to be contacted. We will grant reasonable requests. If you would like to exercise any of these rights, submit a written request to the privacy officer at the location where your business is conducted. Privacy Officers Fort Smith Amanda Caraway 7700 HWY 271 S. Ft. Smith, AR 72908 479-646-7875 Barling Tina Johnson 1610 Fort St. Fort Smith, AR 72908 479-452-1237 Greenwood Kristen Morrison 1530 W. Center Barling, AR72923 479-996-9898 Medical Equipment Mandy McMillan 1210 Cavanaugh Rd. Ft. Smith, AR, 729608 479-649-9500 Changes to this Notice of Privacy Practices We reserve the right to change this Notice. We reserve the right to make the revised or changed Notice effective for PHI we already have about you and any information we receive in the future. We will post a copy of the current Notice. If we change our Notice, you may obtain a copy of the revised Notice upon request. For More Information or to Report a Problem If you have questions about this Notice; contact the Privacy Officer where your business is conducted. If you believe your privacy rights have been violated, you may file a written complaint, and there will be no retaliation, with the Privacy Officer at your location, or with the Secretary of the Department of Health and Human Services, Office for Civil Rights. PATIENT BILL OF RIGHTS 1. Be fully informed in advance about care/services to be provided, including the disciplines that furnish care and the frequency of visits, as well as any modifications to the plan of care; 2. Refuse care or treatment after the consequences of refusing care or treatment are fully presented; 3. Be informed, in writing, of the charges, including payment for care/service expected from third parties and any charges for which the client/patient will be responsible; 4. Have one's property and person treated with respect, consideration and recognition of client/patient dignity and individuality; 5. To obtain service without regard to race, creed, national origin, sex, age, disability, diagnosis or religious affiliation; 6. Be free from mistreatment, neglect, or verbal, mental, sexual and physical abuse, including injuries of unknown source, and misappropriation of client/patient property; 7. 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; 8. Have grievances/complaints regarding treatment or care that is (or fails to be) furnished or lack of respect of property investigated; 9. Confidentiality and privacy of all information contained in the client/patient record and of Protected Health Information; 10. Receive appropriate care without discrimination in accordance with physician orders; 11. Be informed of any financial benefits when referred to an organization; 12. Be fully informed of one's responsibilities. RESPONSIBILITIES OF THE PATIENT 1. To provide complete and accurate information concerning your present health, medication, allergies, etc., when appropriate to your care/service; 2. To be involved, as needed and as able, in developing, carrying out and modifying your home care service plan, such as properly cleaning and storing your equipment and supplies; 3. To properly clean and maintain equipment and supplies; 4. To contact us with any questions or problems concerning your equipment, supplies or service; 5. To notify your attending physician when you feel ill; 6. To notify us prior to changing your place of residence, telephone number, insurance provider or physician; 7. To notify us as soon as possible when encountering any problem including failure, damage, loss or theft with regard to equipment or service; 8. To notify us if your physician modifies or ceases your prescription, service or diagnosis. CUSTOMER CONCERNS • You may contact the privacy officer for your location at the number listed. Within five days of receiving a complaint you will be contacted by telephone, email, fax or letter that we have received your complaint. Within 14 calendar days we will provide a written notification of the results of your inquiry and the resolution. You may also call if you have a concern regarding fraud and abuse or any treatment or services provided by our organization or you may call the Office of Inspector General Hotline at 1-800-447-8477. • MEDICARE DMEPOS SUPPLIER STANDARDS: The products and/or services provided to you by Health Depot are subject to the supplier standards contained in the Federal regulations shown at 42 Code of Federal Regulations Section 424.57(c). These standards concern business professional and operational matters (e.g. honoring warranties and hours of operation). The full text of these standards can be obtained at www.ecfr.gov. We have on display the standards and upon request we will furnish you a written copy of the standards. • Warranty Information: We honor all manufacturer warranties as specified in the product information. If a product is rented, warranties will be extended under applicable law or requirement of insurance during the course of the rental. 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