Heritage Compounding Pharmacy
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Privacy Statement
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. Please review it carefully. Proper Uses or
Disclosures of Protected Health Information
Heritage Compounding Pharmacy (HCP) may use or disclose Protected Health Information
(PHI) for the providing of patient treatment, payment and other health care operations. These
operations include, but are not limited to the following:
1) In the preparation of a formulation or filling of a prescription, the pharmacist would have
communication with the prescriber regarding new prescription information, refill
authorization, and prescription adjustments.
2) To verify and facilitate patient insurance coverage, the pharmacist would have
communication with the insurance company and it’s agents.
3) To transfer to or from another pharmacy, per the patient’s request, the pharmacist would
have communication with another pharmacist.
4) To transmit patient information to a third party, for claims processing.
Other Authorized Uses and Disclosures
HCP is allowed to make certain other uses and disclosures without the patient’s written
authorization. These include, but are not limited to the following:
1) Disclosures of specific patient information to a public health official.
2) Specific patient information in response to a valid court order.
Patient Written Authorization
HCP will obtain from the patient, written authorization for any use or disclosure of PHI not
described in this notice. Written authorization will be made by completing a “Patient Written
Authorization Form” provided by HCP, and by proving at least one form of picture
identification, i.e. driver’s licences . The patient may revoke any written authorization at any
time, with the submission of a request in writing.
All authorizations and revocations will become part of the patient’s record.
Marketing and Patient Contact
HCP may contact the patient in order to provide refill reminders, information on treatment
alternatives, or other health-related benefits or services. To provide written approval to
receive information from HCP in the form of e-mail, fax, or newsletter, please sign the
“Receive Information” box below. HCP will not use or provide patient PHI to be used in any
marketing or promotional programs.
Patients Right's
Patient’s Rights include:
1) The right to inspect and copy his or her PHI records.
2) The right to request an accounting of PHI disclosures not related to treatment, payment,
or health care operations.
3) The right to request an amendment to his or her PHI record. For example the patient may
want to provide, a signed copy of a recent laboratory result for use by the pharmacist, in his
or her record.
4) The right to request additional privacy protections. For example, the patient may want to
prevent certain family members from having access to their PHI. A phone call, followed up
with a written request will implement such a request. The patient may revoke any written
request at any time, with the submission of an additional request in writing. This request will
become part of the patient’s record.
5) The right obtain a paper copy of the notice.
Please take notice– that HCP does not have to agree to the patient’s request.
HCP's Legal Duties
HCP’s legal duties include:
1) Maintain the privacy of the PHI.
2) Provide patients with a notice of its legal duties and privacy practices.
3) Abide by the terms of the notice.
4) Make revision notices available to patients.
