NOTICE OF PRIVACY PRACTICES

434 Hurricane Lane, Williston, VT 05495 802-655-3544 or 1-800-638-1675 Fax 802-655-0123 www.freedompharmacyvt.com

Our company is dedicated to maintaining the privacy of your identifiable health information. In conducting our business, we will create records regarding you and the services we provide to you.

This Notice tells you about the ways in which Freedom Pharmacy (referred to as “we”) may collect, use, and disclose your protected health information and your rights concerning your protected health information. “Protected health information” is information about you that can reasonably be used to serve you and that relates to you, or the payment for that care.

We are required by law to maintain the confidentiality of health information that identifies you; and to provide you with this Notice about your rights and our legal duties and privacy practices with respect to your protected health information. We must follow the terms of this Notice while it is in effect. Some of the uses and disclosures described in this Notice may be limited in certain cases by applicable state laws that are more stringent than the federal standards. If you have questions about this notice, please contact our Privacy Officer for further information.

The terms of this notice apply to all records containing your health information that are created or retained by our organization. We reserve the right to revise or amend our notice of privacy practices. Any revision or amendment to this notice will be effective for all of your records we have created or maintained in the past, and for any of your records we may create or maintain in the future. Our organization will post a copy of our current notice in our office in a prominent location, and you may request a copy of our most current notice by calling us.

We may use and disclose your PHI for different purposes. The examples below are provided to illustrate the types of uses and disclosures we may make without your authorization for payment, home care operations, and treatment.

Payment. We use and disclose your PHI in order bill and collect payment for the services and items you may receive from us. We also may use and disclose your health information to obtain payment from third parties that may be responsible for such costs, such as family members. Also, we may use your health information to bill you directly or services and items. Treatment. We may use and disclose your PHI to coordinate services with other health care providers involved in your care. For example, we may collect measurements to identify appropriate seating and mobility system(s We may obtain and disclose information on CPT diagnosis codes, diagnosis and prognosis, functional limitations, pre-existing health conditions, hospitalizations, prior use of equipment, and information specific to qualifying the patient as dictated by CMN / detailed written order forms. Appointment Reminders. We may use and disclose your health information to contact you and remind you of visits / deliveries / to ask whether you need additional supplies. Release of information to Family / friends. We may release your health information to a friend or family member that is helping you to pay for your health care, or who assists in taking care of you. Disclosures Required by Law. We will use and disclose your health information when we are required to do so by federal, state or local law. We require any business associates to protect the confidentiality of your information and to use the information only for the purpose for which the disclosure is made. We do not provide customer names and addresses to outside firms, organizations, or individuals except in furtherance of our business relationship with you or as otherwise allowed by law.

We restrict access to nonpublic information about you to those employees who need to know that information to provide products or services to you. We maintain physical, electronic, and procedural safeguards that comply with federal standards to guard your personal information.

As Required by Law. We must disclose PHI about you when required to do so by law. Public Health Activities. We may disclose PHI to public health agencies for reasons such as preventing or controlling disease, injury, or disability. Victims of Abuse. Neglect, or Domestic Violence. We may disclose PHI to government agencies about abuse, neglect, or domestic violence. Health Oversight Activities. We may disclose PHI to government oversight agencies. Oversight activities can include, for example, investigations, inspections, audits, surveys, licensure and disciplinary actions; civil, administrative, and criminal procedures or actions; or other activities necessary for the government to monitor government programs, compliance with civil rights laws and the health care system in general. Judicial and Administrative Proceedings. We may disclose PHI in response to a court or administrative order. We may also disclose PHI about you in certain cases in response to a subpoena, discovery request, or other lawful process.

434 Hurricane Lane, Williston, VT 05495 802-655-3544 or 1-800-638-1675 Fax 802-655-0123 www.freedompharmacyvt.com

- Law Enforcement. We may disclose PHI under limited circumstances to a law enforcement official in response to a warrant or similar process; to identify or locate a suspect; or to provide information about the victim of a crime. - To Avert a Serious Threat to Health or Safety. We may disclose PHI about you, with some limitations, when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Special Government Functions. We may disclose information as required by military authorities or to authorized federal officials for national security and intelligence activities. Workers Compensation. We may disclose PHI to the extent necessary to comply with state law for workers’compensation programs.

You have certain rights regarding PHI that we maintain about you. Right To Access Your PHI. You have the right to review or obtain copies of your PHI records, with some limited exceptions. Usually the records include referral information, delivery forms, billing, claims payment, and medical management records. Your access to records can include PHI maintained electronically even if not an electronic health record. Your request to review and/or obtain a copy of your PHI records must be made in writing. We may charge a fee for the costs of producing, copying, and mailing your requested information, but we will tell you the cost in advance. Right To Amend Your PHI. If you feel that PHI maintained by us is incorrect or incomplete, you may request that we amend the information. Your request must be made in writing and must include the reason you are seeking a change. We may deny your request if, for example, you ask us to amend information that was not created by us, or you ask to amend a record that is already accurate and complete. If we deny your request to amend, we will notify you in writing. You then have the right to submit to us a written statement of disagreement with our decision and we have the right to rebut that statement. Right to Notification of Breach or Accounting of Disclosures. You have the right to be notified following a breach of your unsecured PHI. This will not include our disclosures related to your treatment, our payment or health care operations, or disclosures made to you or with your authorization. It may also exclude certain other disclosures, such as for national security purposes. You will be notified of any unauthorized release or access to your PHI. Your request for an accounting of disclosures must be made in writing and must state a time period for which you want an accounting. This time period may not be longer than six years. Your request should indicate in what form you want the list (for example, on paper or electronically We may charge for providing the accounting, but we will tell you the cost in advance. Right To Request Restrictions on the Use and Disclosure of Your PHI. You have the right to request that we restrict or limit how we use or disclose your PHI for services, payment, or health care operations. You may restrict disclosures of PHI if you have paid out-of-pocket in full for the health care item or service. Your request for a restriction must be made in writing. In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit how we use or disclose your information, or both; and (3) to whom you want the restrictions to apply. Right To Receive Confidential Communications. You have the right to request that we use a certain method to communicate with you or that we send information to a certain location. For example, you may ask that we contact you at work rather than at home. Your request to receive confidential communications must be made in writing. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted. Right to a Paper Copy of This Notice. You have a right at any time to request a paper copy of this Notice. You may ask us to give you a copy of this notice at any time. Contact Information for Exercising Your Rights. You may exercise any of the rights described above by contacting our privacy Office. Complaints. If you believe that your privacy rights have been violated, you may file a complaint with us and/or with the Office of Civil Rights.

All complaints must be submitted in writing. You will not be penalized for filing a complaint. This Notice of Privacy Practices is effective as of December 20th, 2013

I acknowledge receipt of Freedom Pharmacy’ Notice of Privacy Practices. You may complete and mail to Freedom Pharmacy, 434 Hurricane Lane, Williston, VT 05495