APPOMATTOX DRUG STORE NOTICE OF PRIVACY PRACTICES EFF. DATE 4/14/03

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 medical information about you and your health is personal. Appomattox Drug Store is required by law to maintain the privacy of your health information, to follow the terms of this Notice, and to provide you with this Notice of our legal duties and practices with respect to your health information. We are required to follow the terms of the Notice that is currently in effect. A paper copy of this Notice may be obtained upon request.

How Appomattox Drug Store May Use or Disclose Your Health Information
Appomattox Drug Store protects the privacy of your health information. For some activities, we must have your written authorization to use or disclose your health information. However, the law permits Appomattox Drug Store to use or disclose your health information for the following purposes without your authorization:
For Treatment. Information obtained by the Pharmacy will be used to dispense prescriptions to you. We may disclose health information about you to pharmacists and other persons who are involved in dispensing your prescriptions.
For Payment. We may use and disclose your health information so that your pharmacy services may be billed to, and payment may be collected from you, an insurance company, or a third party.
For Health Care Operations. We may use and disclose health information about you for pharmacy operations. Unless you provide us with alternative instructions, we may send refill reminders, statements of accounts, and other materials related to your health care to your home. These uses and disclosures are necessary to run the Pharmacy and make sure that you receive quality customer service.
As Require by Law. We will disclose health information about you 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 health information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure, however, would only be to someone able to help prevent the threat.
Public Health Risks. We may disclose health information about you for public health activities. These activities generally include the following: (1) to prevent or control disease, injury or disability; (2) to report reactions to medications or problems with products; (3) to notify people of recalls of products they may be using; (4) to notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition; and (5) to notify the appropriate government authority if we believe a person has been the victim of abuse, neglect, or domestic violence (we will only make this disclosure if you agree and when required or authorized by law).
For Health Oversight Activities. We may disclose health information 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, includes audits, investigations and licenser.
Lawsuits and Disputes. If you are involved in a lawsuit or dispute, we may disclose health information about you in response to a court order or administrative order. We may also disclose health information about you in response to a subpoena, a discovery request or other lawful process by someone else involved in the dispute, but only of efforts have been made to tell you about the request (which may include written notice to you) or to obtain an order protecting the information requested.
For Specific Government Functions. Appomattox Drug Store may disclose health information for the following specific government functions: (1) health information of military personnel, as required by military command authorities; (2) health information of inmates, to a correctional institution or law enforcement officials; (3) in response to a request from law enforcement, if certain conditions are satisfied; and (4) for national security reasons.

When Appomattox Drug Store May Not Use or Disclose Your Health Information
Except as described in this Notice, Appomattox Drug Store may not use or disclose your health information without your written authorization. If you do authorize Appomattox Drug Store to use or disclose your health information for another purpose, you may revoke your authorization in writing at any time.

You Have the Following Rights With Respect to Your Health Information
You have the right to request restrictions on certain uses and disclosures of your health information. Appomattox Drug Store is not required to agree to a restriction that you request. If we do not agree to any restriction, we will put the agreement in writing and follow it, except in emergency situations. We cannot agree to limit the uses or disclosures of information that are required by law.
You have the right to inspect and copy your health information as long as the Pharmacy maintains the health information. Your health information usually will include prescription and billing records. To inspect a copy your health information, you must submit a written request or call Appomattox Drug Store. We may deny your request to request and copy in certain limited circumstances. If you are denied access to your health information, you may request that the denial be reviewed. You have a right to choose to obtain a summary instead of a copy of a copy of your health information.
You have the right to request that Appomattox Drug Store amend your health information that is incorrect or incomplete. To request an amendment, you must submit a written request to Appomattox Drug Store (form available from your pharmacist), along with the reason for the request. Appomattox Drug Store is not required to amend health information that is accurate and complete. Appomattox Drug Store will provide you with information about the procedure for addressing any disagreement with a denial.
You have the right to receive an accounting of disclosures of your health information we have made after April 14, 2003 for purposes other than disclosures: (1) for Appomattox Drug Store’s treatment, payment, or health care operation; (2) to you or based upon your authorization; and (3) for certain government functions. To request an accounting, you must submit a written request to Appomattox Drug Store. You must specify the time period, which may not be longer than six years.
You may request communications of your health information by alternative means or at alternative locations. For example, you may request that we contact you about health matters only in writing or at a different resident or post office. To request confidential communication of your health information, you must submit a written request or call Appomattox Drug Store. Your request must state how or when you would like to be contacted. We will accommodate all reasonable requests.

If you would like to exercise one or more of these rights, contact Appomattox Drug Store, 2046 Confederate Blvd., Appomattox, VA 24522.

Changes to this Notice of Privacy Practices
Appomattox Drug Store reserves the right to change this Notice. We reserved the right to make the revised or changed Notice effective for health information we already have about you as well as any information we receive in the future. Any revised Notice will be posted in the Pharmacy. Upon request, we will provide a revised Notice to you.

For More Information or to Report a Problem
If you have questions or would like additional information about Appomattox Drug Store’s privacy practices, you may contact the drug store, Appomattox Drug Store, 2046 Confederate Blvd., Appomattox, VA 24522 or call 434-352-7161. If you believe your rights have been violated, you can file a complaint with Appomattox Drug Store. There will be no retaliation for filing a complaint.

APPOMATTOX DRUG STORE
2046 CONFEDERATE BLVD.
APPOMATTOX, VA 24522