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.

A. OUR COMMITMENT TO YOUR PRIVACY
Church Square Pharmacy Inc. is dedicated to maintaining the privacy of your medical information. In conducting our business, we will create records regarding you and the treatment and services we provide to you. These records are our property. However, we are required by law to maintain the confidentiality of your medical information, to provide you with this notice of our legal duties and privacy practices concerning your medical information, and to follow the terms of our notice of privacy practices in effect at the time. To summarize, this notice provides you with the following important information: how we may use and disclose your medical information, your privacy rights in your medical information, and our obligations concerning the use and disclosure of your medical information.

Changes To This Notice
The terms of this notice apply to all records containing your medical information that are created or retained by Church Square Pharmacy Inc. We reserve the right to revise, change, or amend our notice of privacy practices. Any revision or amendment to this notice will be effective for all of the information that we already have about you, as well as any of your medical information that we may receive, create, or maintain in the future. We will post a copy of our current notice in our pharmacy in a prominent location. We will also post our current notice on our website (if applicable). You may request a copy of our most current notice during any visit to the pharmacy.

B. HOW WE MAY USE AND DISCLOSE YOUR MEDICAL INFORMATION
The following paragraphs describe the different ways we may use and disclose your medical information. Please note that each particular use or disclosure is not listed below. However, the different ways we are permitted to use and disclose your medical information do fall within one of the categories.

Treatment
Church Square Pharmacy Inc. may use and disclose your medical information to treat you. For example, we may use your medical information to dispense prescription medications to you or to advise you of possible side effects of your medications. We may disclose your medical information to another pharmacist acting on your behalf or to a certified or licensed health care professional responsible for your care when they or we need to obtain or clarify information to provide treatment to you. For example, we may disclose your medical information to another pharmacy where you may be getting prescriptions or to a pharmacy you have contacted requesting transfer of your prescription records. In the course of providing treatment to you, our pharmacy may use your name to reference your prescriptions or other services you receive from us. We may disclose your medical information to another person that you have asked to assist you with obtaining our services, such as a family member, close personal friend, or any other person identified by you. We will limit the information disclosed to that which is directly relevant to the person’s involvement with your care. For example, we may disclose minimal information to a person that you have sent to our pharmacy to pick up your prescriptions.

Payment
Church Square Pharmacy Inc. may use and disclose your medical information to bill and collect payment for services and items we have provided to you. For example, we may contact your health insurer or the manager of your prescription drug benefit to certify that you are eligible for benefits or the amount of your prescription co-payment. We may use and disclose your medical information to obtain payment from other people who may be responsible to pay for your health care, such as family members. We may use your medical information to bill you directly for services and items. Please note that the information on or provided with the bill may contain information that identifies you and the medications you are taking.

Health Care Operations
Church Square Pharmacy Inc. may use and disclose your medical information in the operation of our business. These uses are important to ensure that you receive quality care and our pharmacy operates efficiently. For example, we may use and disclose your medical information to evaluate the performance of the pharmacists providing treatment to you, to conduct cost-management analyses for the services we offer to our patients and for the purposes of business planning.

Additional ways we may use or disclose your medical information:
In addition to the ways we have identified above for treatment, payment, or health care operations, Church Square Pharmacy Inc. will use and disclose your medical information as follows:

• Required by Law
  Church Square Pharmacy inc. may use or disclose medical information about you when required to do so by applicable law.
• Public Health Activities
  Church Square Pharmacy Inc. may disclose your medical information to a public health authority that is authorized by law to collect or receive such information for the purpose of preventing or controlling disease, injury or disability; preventing child abuse or neglect; or preventing the spread of communicable diseases. We may also disclose your medical information to a public health authority that is authorized by law to collect or receive information about the quality, safety, or effectiveness of prescription and nonprescription medications and medical devices.
• Immunization Records
  Church Square Pharmacy Inc. may disclose your medical immunization records to schools required by law to have proof of immunization prior to admission. The authorization may be given orally but this must be documented.
• Abuse, Neglect, and Domestic Violence
  Church Square Pharmacy Inc. may disclose your medical information to a government authority that is authorized by law to receive reports of adult victims of abuse, neglect or domestic violence if we suspect you are a victim of such abuse, neglect or domestic violence. If we make such a disclosure, we will inform you or your personal representative of the report, unless we believe that by informing you or your personal representative we will be placing you at risk of serious harm.
• Health Oversight Activities
  Church Square Pharmacy Inc. may disclose your medical information to a health oversight agency for oversight activities authorized by law. Such oversight activities include 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. The Board of Pharmacy and Drug Control Branch of the state’s Cabinet for Health Services are examples of some of the health oversight agencies to which we disclose medical information.
• Lawsuits and Similar Proceedings
  Church Square Pharmacy inc. may use and disclose your medical information in response to a court or administrative order, if you are involved in a lawsuit or similar proceeding.
• Law Enforcement
  Church Square Pharmacy inc. may disclose your medical information to a federal, state, or municipal law enforcement officer whose duty is to enforce the laws of this state or the United States relating to drugs and who is engaged in a specific investigation involving a designated person.
• Specialized Government Functions
  Church Square Pharmacy Inc. may disclose your medical information if you are a member of U.S. or foreign military forces (including veterans) and if required by the appropriate military command authorities. In addition, we may disclose your medical information to federal officials for intelligence and national security activities authorized by law. We may disclose your medical information to federal officials in order to protect the President, other officials or foreign heads of state, or to conduct investigations. We may disclose your medical information to correctional institutions or law enforcement officials if you are an inmate or under the custody of a law enforcement official. Disclosure for these purposes would be necessary: (i) for the institution to provide health care services to you, (ii) for the safety and security of the institution, and/or (iii) to protect your health and safety or the health and safety of other individuals.
• Workers’ Compensation and Other Government Agencies
  Church Square Pharmacy Inc. may disclose your medical information to Workers’ Compensation and other government agencies charged with the responsibility of providing medical care for you, upon written request by an authorized representative of the agency requesting such information.
• Treatment Alternatives
  Church Square Pharmacy Inc. may use your medical information to inform you of health-related benefits and services or alternative treatments, therapies, providers, or settings of care that may be of interest to you. For example, we may contact you to provide refill reminders, to invite you to a health screening or to participate in a program we believe may be beneficial to your health.
• Marketing
  Church Square Pharmacy Inc. may communicate with you about a product or service and encourage you to purchase or use that product or service in the course of treatment. These communications must either take place face-to-face with you or concern products or services of nominal value.
• Disclosure to Decedent Family Members
  Church Square Pharmacy Inc. may communicate with your family member, relative, close personal friend or other person identified by you, any protected health information directly relevant to that person’s involvement in your care, unless you notified us otherwise prior to your death.

C. YOUR RIGHTS REGARDING YOUR MEDICAL INFORMATION
Requesting Restrictions
You have the right to request a restriction in Church Square Pharmacy Inc.’s use or disclosure of your medical information for treatment, payment, or health care operations. Additionally, you have the right to request that we limit our disclosure of your medical information to individuals involved in your care or the payment for your care, such as family members and friends. We are not required to agree to your request if it is necessary for treatment, healthcare operations or payment of services. If we do agree to your request, we are bound by our agreement except when otherwise required by law or in the case of an emergency. You have the right to request we do not disclose your medical information to your health plan for services that were paid out of pocket in full. If you have paid for the product or service out-of-pocket in full we are required to honor your request unless your medical information is needed for treatment. In order to request a restriction in our use or disclosure of your medical information, you must make your request in writing to the Privacy Officer at Church Square Pharmacy Inc.. Your request must describe in a clear and concise fashion: (i) the information you wish restricted; (ii) whether you are requesting to limit our practice’s use, disclosure or both; and (iii) to whom you want the limits to apply.

Psychotherapy Notes
Your health information in the form of psychotherapy notes (where appropriate) will not be used or disclosed unless required or permitted under federal and state law. If Church Square Pharmacy Inc. wishes to use or disclose your psychotherapy notes (where appropriate) we must obtain written authorization from you unless the use or disclosure if required or permitted under federal and state law.

Marketing
Your health information will not be used for marketing except as permitted under (B) above. If Church Square Pharmacy Inc. wishes to use your health information for marketing we must obtain written authorization from you for this marketing.

Fundraising
Your health information will not be used for fundraising activities. If Church Square Pharmacy Inc. wishes to use your health information for fundraising we must obtain written authorization from you for this fundraising. I understand that I have the right to Opt-out of any fundraising activities.

Sales of Health Information
Your health information will not be sold. If Church Square Pharmacy Inc. wishes to sale your health information we must obtain written authorization from you for this fundraising.

Confidential Communications
You have the right to request that Church Square Pharmacy Inc. communicate with you about your health and related issues in a particular manner, or at a certain location. For instance, you may ask that we contact you by mail, email, or other electronic means rather than by telephone, or at home, rather than work. In order to request a type of confidential communication, you must make a written request to the Privacy Officer at Church Square Pharmacy inc. specifying the requested method of contact, or the location where you wish to be contacted. Our pharmacy will accommodate reasonable requests. You do not need to give a reason for your request.

Inspection and Copies
You have the right to inspect and obtain a copy of the information that Church Square Pharmacy Inc. may use to make decisions about your care, including prescription records and billing records. You must submit your request in writing to the Privacy Officer at Church Square Pharmacy Inc. in order to inspect and/or obtain a copy of your records. We may charge a fee for the costs of copying, mailing, labor and supplies associated with your request. We may deny your request to inspect and/or copy in certain limited circumstances. You may, however, request a review of our denial. The review of our denial will be conducted by another licensed health care professional chosen by us, but not by the person that originally denied your request.

Amendment
You may ask Church Square Pharmacy Inc. to amend your medical information if you believe it is incorrect or incomplete. You may request an amendment for as long as the information is kept by or for our pharmacy. To request an amendment, your request must be made in writing and submitted to the Privacy Officer at Church square Pharmacy Inc, You must provide us with a reason that supports your request for amendment. We will deny your request if you fail to submit your request (and the reason supporting your request) in writing. Also, we may deny your request if you ask us to amend information that is accurate and complete; not part of the medical information kept by or for Church Square Pharmacy Inc.; not part of the medical information which you would be permitted to inspect and copy; or not created by Church Square Pharmacy Inc., unless the individual or entity that created the information is not available to amend the information.

Accounting of Disclosures
You have the right to request an accounting of disclosures. An accounting of disclosures is a list of certain disclosures Church square Pharmacy has made of your medical information. In order to obtain an accounting of disclosures, you must submit your request in writing to the Privacy Officer at Church Square Pharmacy Inc.. All requests for an accounting of disclosures must state a time period that may not be longer than six years and may not include dates before April 14, 2003. The first request within a 12-month period is free of charge, but we may charge you for additional requests within the same 12-month period. We will notify you of the costs involved with additional requests, and you may withdraw your request before you incur any costs.

Right to a Paper or Electronic Copy of This Notice
You are entitled to receive a paper or electronic copy of our notice of privacy practices. You may ask us to give you a copy of this notice at any time. To obtain a copy of this notice, contact the Privacy Officer at Church Square Pharmacy Inc.

Right to File a Complaint
If you believe your privacy rights have been violated, you may file a complaint with Church Square Pharmacy Inc. or with the Secretary of the Department of Health and Human Services, Hubert H. Humphrey Building, 200 Independence Avenue SW, Washington, DC 20201. To file a complaint with our organization, contact the Privacy Officer at Church Square Pharmacy Inc. All complaints must be submitted in writing. You will not be penalized for filing a complaint.

Right to be Notified of Breach of Unsecure PHI
You have the right to be notified of a breach of your unsecured protected health information as required by federal and state law.

Right to Provide an Authorization for Other Uses and Disclosures
Church Square Pharmacy Inc. will or must obtain a written authorization for uses or disclosure not identified by this notice or not permitted by applicable law. You have the right to revoke any authorization you provide to us regarding the use and disclosure of your medical information at any time. Your revocation must be in writing. Upon receipt of your written revocation, we will no longer use or disclose your medical information for the reasons described in the authorization. Of course, we are unable to take back any disclosures we have already made with your permission. Please also note that we are required to retain records of your care.
Right to be notified of a breach of unsecured Protected Health Information
[PHARMACY NAME] will notify

D. CONTACT INFORMATION
You may contact the Privacy Officer for Church Square Pharmacy Inc. at:
Privacy Officer
Church Square Pharmacy Inc.
14529 Puritas Ave.
Cleveland Ohio, 44135

E. EFFECTIVE DATE
This Notice is effective September 23, 2013.