SYNERGY PHARMACY SERVICES
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.
I. Our Duty to Safeguard Your Protected Health Information
We are committed to preserving the privacy and confidentiality of your health information. Copies of our privacy policies and procedures are maintained in our business office. We are required to provide you with this Privacy Notice that contains information regarding our
privacy practices to explain how, when and why we may use or disclose your PHI and your rights and our obligations regarding any such
uses or disclosures. Except in specified circumstances, we must use or disclose only the minimum amount of PHI necessary to accomplish the intended purpose of the use or disclosure of such information.
We reserve the right to change this notice at any time and to make the revised or changed notice effective for PHI that we already have
about you as well as any information we receive in the future about you. Should we revise/change this Privacy Notice, we will promptly
inform you of such changes. You also may request and obtain a copy of any new/revised Privacy Notice from the contact person identified on the last page of this notice.
Should you have questions concerning our Privacy Notice, our contact information is listed on the last page of this document.
II. How We May Use and Disclose Your Protected Health Information
We have a limited right to use and/or disclose your protected health information for purposes of treatment, payment, or for health care
operations. For other uses and disclosures, you must give us your written authorization to release your protected health information
unless the law permits or requires us to make the use or disclosure without your authorization.
Should it become necessary to release or give access to your protected health information to an outside party performing services on our behalf (e.g., maintaining our computers), we will require the party to have a signed agreement with us that the party will extend the same degree of privacy protection to your information as we do.
The privacy law permits us to make some uses or disclosures of your protected health information without your consent or authorization. The following describes each of the different ways that we may use or disclose your protected health information. Where appropriate, we have included examples of the different types of uses or disclosures. These include:
1. Use and Disclosures Related to Treatment
2. Use and Disclosures Related to Payment
3. Use and Disclosures Related to Health Care Operations
4. Use and Disclosures Related to Treatment Alternatives, Health-Related Benefits and Services
III. Uses and Disclosures Requiring Your Written Authorization
For uses and disclosures of your protected health information beyond the above excepted purposes, we are required to have your
written authorization, except as otherwise required or permitted by law. You have the right to revoke an authorization at any time to stop future uses or disclosures of your information except to the extent that we have already undertaken an action in reliance upon your
authorization. Your revocation request must be provided to us in writing. Please contact us for purposes of revoking your authorization. Copies of the forms are available upon request.
IV. Uses or Disclosures of Information Based Upon Your Verbal Agreement
We may disclose a limited amount of your protected health information if we provide you with an advance oral or written notice and you do not object to such release or such release is not otherwise prohibited by law. However, if there is an emergency situation and you are
unable to object (e.g., because you were not present or you were incapacitated), disclosure may be made if it is consistent with any prior
expressed wishes and disclosure is determined to be in your best interest. When a disclosure is made based on these or emergency
situations, we will only disclose protected health information relevant to the person’s involvement in your care. You will be informed and given an opportunity to object to further disclosures of such information as soon as you are able to do so.
We may disclose your protected health information to your family members and friends who are involved in your care or who help pay for your care. We may also disclose your protected health information to a disaster relief organization for the purposes of notifying your
family and/or friends about your general condition, location, and/or status (i.e., whether you are alive or dead). You may object to the
release of this information. Our contact information is listed on the last page of this document.
V. Uses and Disclosures of Information That Do Not Require Your Consent or Authorization
State and federal laws and regulations in some instances either require or permit us to use or disclose your protected health information without your consent or authorization. The uses or disclosures that we may make without your consent or authorization are extensive.
For a complete listing and use of these disclosures, please contact us. Our contact information is listed on the last page of this document.
VI. Your Rights Regarding Your Protected Health Information
You have the following rights concerning the use or disclosure of your protected health information that we create or that we may
maintain about you:
1. To Request Restrictions on Uses and Disclosures of Your Protected Health Information
2. The Right to Inspect and Copy Your Health and Billing Records:
3. The Right to Amend or Correct Your Protected health information:
4. The Right to Request Confidential Communications:
5. The Right to Request an Accounting of Disclosures of Protected Health Information:
VI. How to File a Complaint About Our Privacy Practices
If you have reason to believe that we have violated your privacy rights or our privacy policies and procedures, or if you disagree with a
decision we made concerning access to your protected health information, you have the right to file a complaint with us or the Secretary
of the U.S. Department of Health and Human Services. You will not be retaliated against for filing a complaint.
Record of Acknowledgment / Documentation of Good Faith Effort to Obtain Acknowledgment
Resident/Patient Name:__________________________________________________ Date:______________________
Contact Information for Questions, Complaints or Requests Regarding Your Health Information
Should you have any questions concerning our privacy practices, obtaining a copy of our privacy notice, requesting restrictions on the
release of your information, revoking an authorization, amending or correcting your protected health information, obtaining an
accounting of our disclosures of your protected health information, requesting inspection or copying of your medical information,
requesting that we communicate information about your health matters in a certain way, filing complaints, or any other concerns you may have relative to our privacy practices, please contact:
Synergy Rx HIPAA Compliance Officer
31201 US HWY 19N | Suite 2 | Palm Harbor, FL 34684
If you wish, you may also file a complaint with the Secretary of the U.S. Department of Health and Human Services. You may mail your
complaint to U.S. Department of Health and Human Services, 200 Independence Avenue, S.W., Washington, DC 20201; or you may call
(202) 619-0257 or 1-877-696-6775 (toll free); or you may log on to the internet address, http://www.hhs.gov/ocr.
Acknowledgment / Good Faith Effort to Obtain Acknowledgment (check one of the following)
[ ] I certify that I received a copy of the above-named entity’s Privacy Notice and that I have had an opportunity to review this document
and ask questions to assist me in understanding my rights relative to the protection of my health information. I am satisfied with the
explanations provided to me and I am confident that the above-named entity is committed to protecting my health information.
[ ] I certify that I am the authorized representative of above-identified patient, and that I have received the Privacy Notice on behalf of
this individual and that the above-named entity provided me with an opportunity to review this document and ask questions to assist me
in understanding the patient’s privacy rights. I am satisfied with the explanations provided to me and I am confident that the
above-named entity is committed to protecting health information.
Date:________________ Signature of Representative:___________________________________________________
Relationship to Individual:______________________________________________________
[ ] I, _____________________________, certify that I made a good faith effort to obtain the acknowledgment of the above-identified [resident/
patient] or his/her personal representative that he/she had received a copy of the Privacy Notice of the above-identified entity, but was
unable to obtain such acknowledgment for the following reason(s):
[ ] [Resident/Patient] or personal representative refused to sign.
[ ] [Resident/patient] or personal representative was unavailable to sign.
[ ] Other:_____________________________________________________________
A copy of this document must be provided to the person to whom the Privacy Notice was provided and a copy must be filed in the