SEQUON INC. HIPAA NOTICE OF PRIVACY PRACTICES
PLEASE REVIEW IT CAREFULLY
This Notice of Privacy Practices describes how we may use and disclose your protected health information (PHI) to carry out treatment,
payment or health care operations (TPO) and for other purposes that are permitted or required by law. It also describes your rights to
access and control your protected health information. “Protected health information” is information about you, including demographic
information, that may identify you and that relates to your past, present, or future physical or mental health or condition and related
healthcare services.
Uses and Disclosures of Protected Health Information: Your protected health information may be used and disclosed by our
organization, our office staff and others outside of our office that are , involved in your care and treatment for the purpose of providing
health care services to you, to pay your health care bills, to support the operation of the organization, and any other use required by
law.
Treatment: We will use and disclose your protected health information to provide, coordinate, or manage your health care and any
related services. This includes the coordination or management of your healthcare with a third party. For example, we would disclose
your protected health information, as necessary, to a home health agency that provides care to you. For example, your protected health
information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information
to diagnose or treat you.
Payment: Your protected health information Will be used, as needed, to obtain payment for your health care services. For example,
obtaining approval for equipment or supplies coverage may require that your relevant protected health information be disclosed to the
health plan to obtain approval for coverage.
Healthcare Operations: We may use or disclose, as needed, your protected health information in order to support the business
activities of our organization. These activities include, but are not limited to, quality assessment activities, employee review activities,
accreditation activities, and conducting or arranging for other business activities. For example, we may disclose your protected health
information to accrediting agencies as part of an accreditation survey. We may also call you by name while you are at our facility. We
may use or disclose your protected health information, as necessary, to contact you to check the status of your equipment.
We may use or disclose your protected health information in the following situations without your authorization: as Required
By Law, Public Health issues as required by law, Communicable Diseases, Health Oversight, Abuse or Neglect, Food and Drug
Administration requirements, Legal Proceedings, Law Enforcement, Criminal Activity, Inmates, Military Activity, National Security, and
Workers' Compensation. Required Uses and Disclosures: Under the law, we must make disclosures to you and when required by the
Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of
Section 164.500.
Other Permitted and Required Uses and Disclosures Will Be Made Only with Your Consent, Authorization or Opportunity to
Object, unless required by law.
You may revoke this authorization, at any time, in writing, except to the extent that your physician or this organization has taken an
action in-reliance on the use or disclosure indicated in the authorization.
Your Rights: Following is a statement of your rights with respect to your protected health information.
You have the right to inspect and copy your protected health information. Under federal law, however, you may not inspect or
copy the following records: psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or
administrative action or proceeding, and protected health information that Is subject to law that prohibits access to protected health
information.
You have the right to request a restriction of your protected health information. This means you may ask us not to use or
disclose any part of your protected health information for the purposes of treatment, payment or healthcare operations. You may also
request that any part of your protected health information not be disclosed to family members or friends who may be involved in your
care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction
requested and to whom you want the restriction to apply.
Our organization is not required to agree to a restriction that you may request. If our organization believes it is in your best interest to
permit use and disclosure of your protected health information, your protected health information will not be restricted. You then have
the right to use another Healthcare Professional.
You have the right to request to receive confidential communications from us by alternative means or at an alternative
location.
You have the right to obtain a paper copy of this notice from us upon request, even if you have agreed to accept this notice
alternatively, e.g., electronically.
You may have the right to have our organization amend your protected health information. If we deny your request for
amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will
provide you with a copy of any such rebuttal.
You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information.
We reserve the right to change the terms of this notice and will inform you by mail of any changes. You then have the right to object or
withdraw as provided in this notice.
Contacting Us:
1. Additional Questions, Submitting Requests or Complaints
a. If you have questions about this Notice or how Guardian Pharmacy of Maine uses and discloses your protected health information
please contact our Privacy Officer below.
b. You may obtain forms needed for request submission from our pharmacy or from our Privacy Officer.
c. If you believe your privacy rights have been violated you may file a complaint with our Privacy Officer or with the Secretary of Health
and Human Services. You will not be retaliated against for filing a complaint.
2. Privacy Officer
Sam Brackett
Terrapin Pharmacy
601 Chinquapin Round Rd.
Annapolis, MD 21401
410-837-0200
3. Secretary of Health and Human Services, Office for Civil Rights
a. For online complaint forms and contact information for the Regional OCR offices:
http://www.hhs.gov/ocr/privacy/index.html
b. Email: OCRComplaint@hhs.gov for assistance or questions about complaint forms
We are required by law to maintain the privacy of, and provide individuals with, this notice of our legal duties and privacy practices
with respect to protected health information, if you have any questions, concerns, or objections to this form, please ask to speak with
our President in person or by phone at 443-837-0200 Associated companies with whom we may do business, such as an
answering service or delivery service, are given only enough information to provide the necessary service to you. No medical
information is provided.
We welcome your comments: Please feel free to call us if you have any concerns about how we protect your privacy. Our goal is
always to provide you with the highest quality services.
© 2005, 2006, 2007 Affordable Health Care Consultants