PRIVACY NOTICE

Cook Medical Supply/ CMS Pharmacy Notice of Health Information Practices

This notice describes how information about you may be used and disclosedand how you can get access to this information. Please review it carefully.

►  Understanding Your Health Record/Information

Each time you visit a hospital, physician, or other healthcare provider, a record of your visit is made. Typically, this record contains your symptoms, examination and test results, diagnoses, treatment, and a plan for future care or treatment. This information, often referred to as your health or medical record, serves as a:

• basis for planning your care and treatment
• means of communication among 1he many health professionals who contribute to your care
• legal document describing the care you received
• means by which you ora third-party payer canverify thatservices billed were actually provided
• a tool in educating health professionals
• asource of data formedical research
• a source of information for public healthofficials charged with improving the health of the nation
• a source of data for facility planning and marketing
• a tool with which we canassess and continually work to improve the care we render and the outcomes we achieve.

Understanding what is in your record and how your record and how your health information is used helps you to:

• ensure its accuracy
• better understand who, what, when, where, and why others may access your health information
• make more informed decisions when authorizing disclosure to others

► Your Health Information Rights

Although your health record is the physical property of the healthcare practitioner or facility that compiled it, the information belongs to you. You have the right to:

• Request a restriction on certain usesand disclosures of your information asprovided by 45 CFR 164.522
• obtain a paper copyof the notice or information practices upon request
• inspect and copy your health record as provided for in 45 CFR 164.524
• amend your health record as providedfor in45 CFR 164.528
• obtain an accounting of disclosuresof your health information as provided in 45 CFR 164.528
• request communications of your health information by alternative means or at alternative locations
• revoke your consent to use or disclose health information except to the extent that action has already been taken.

►  OurResponsibilities

Cook Medical Supply/ CMS Pharmacy is required to:

• maintain the privacy of your health information
• provide you with a noticeas to our legal dutiesand privacy practiceswith respect to information we collect and maintain about you
• abide by the terms of this notice
• notify you if we areunable to agree to a requested restriction
• accommodate reasonable requests you may have to communicate health information by alternative means or at alternative locations.

We reserve the right to require that requests be made in writing and to change our practices and to make the new provisions effective for all protected health information we maintain. Should our information practices change, we will mail a revised notice to the addressyou've supplied us.

We will not use or disclose your health information without your authorization, except as described in this notice.

► For More Information or to Report a Problem

lf you have questions and would like additional information, you man contact us at (601)732-6334.

If you believe your privacy rights have been violated, you can file a complaint with our receptionist at the above number or with the secretary of Health and Human Services.There will be no retaliation for filing a complaint.

►  Examples of Disclosures for Treatment, Payment and Health Operations

♦  We will use your health information for treatment.

For Example: Information obtained by a nurse practitioner, nurse, physician, or other member of your healthcare team will be recorded in your record and used to determine the course of treatment that should work best for you. Your provider will document in your record his or her expectations of the members of your healthcareteam. Members of yourhealthcare team will then record the actions they took and their observations. In that way, the provider will know how you are responding to treatment.

♦  Wewill use your health information for payment.

For Example:A bill may be sent to you or a third-party payer. The information on or accompanying the bill may include information that identifies you, as well as your diagnosis, procedures, and supplies used.

•  We will use your health information fur regular health operations.

ForExample: Members of the medical staff or office managementmay use information in your health record to assess the care and outcomes in your case and others like it. This information will then be used in an effort to continually improve the quality and effectiveness of the healthcare and service we provide.

Business associates: There are some services provided in our organization through contacts with business associates. Examples include professional insurancebilling services, collection agency, certain laboratory tests, attorney and accountant. When these services are contracted, we may disclose your third-party payer or other identifiable information for services rendered. To protect your health information, however, we require the business associate to appropriately safeguard your information.

Notification: We may use or disclose information to notify or assist in notifying a family member, personal representative, or another person responsible for your care, your location, and general condition.

Communication with family: Health professionals, using their best judgment, may disclose to a family member, other relative,close personal friend or any other personyou identify, healthinformation relevant to that person's involvement in your care or payment related to your care.

Marketing: We may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you.

Food and Drug Administration (FDA): We may disclose to the FDA health information relative to adverse events with respect to food, supplements, product and product defects, or post marketing surveillance information to enable product recalls, repairs, or replacement.

Workers’ compensation: We may disclose health information to the extent necessary to comply with laws relating to workers compensation or other similar programs established by law.

Public health: As required by law, we may disclose your health information to public health or legal authorities charged with preventing or controlling disease, injury, or disability.

Correctional institution: Should you be an inmate of a correctional institution; we may disclose to the institution or agents thereof health information necessary for your health and the health and safety of other individuals.

Law enforcement: We may disclose healthinformation for law enforcement purposes as required by law or in response to a valid subpoena.

Federal law makesprovision for your health information to be released to an appropriate health oversight agency, public health authority or attorney, provided that a work force member or business associate believes in good faith that we have engaged in unlawful conductor have otherwise violated professional or clinical standards and are potentially endangering one or more patients, workers or the public.

Effective Date: April 14, 2003