HIPAA Notice of Privacy Practices

Our Legal Duty

FourSquare Pharmacy Packaging Services (“FourSquare,” “we,” “us,” or “our”) is required by law to maintain the privacy of protected health information (“PHI”) and to provide you with notice of our legal duties and privacy practices with respect to PHI. We are required to abide by the terms of the notice currently in effect.

“Protected Health Information” is information about you, including demographic information, that may identify you and relates to your past, present, or future physical or mental health condition, the provision of healthcare to you, or the past, present, or future payment for such healthcare.

How We May Use and Disclose Your PHI

For Treatment

We may use or disclose your PHI to provide you with pharmacy services and coordinate your care with other healthcare providers. For example, we may share your medication information with your prescribing physician or nursing facility to ensure appropriate treatment.

For Payment

We may use or disclose your PHI to bill for pharmacy services and receive payment from you, your health plan, Medicare, Medicaid, or other payers.

For Healthcare Operations

We may use or disclose your PHI to support our business activities, including quality improvement, staff training, accreditation, and legal compliance.

As Required by Law

We will disclose your PHI when required to do so by federal, state, or local law, including for public health activities, abuse or neglect reporting, food and drug safety, and law enforcement purposes as permitted or required by law.

Uses and Disclosures Requiring Your Authorization

Other than as described above, we will only use or disclose your PHI with your written authorization. This includes:

• Most uses and disclosures of psychotherapy notes
• Uses and disclosures of PHI for marketing purposes
• Disclosures that constitute a sale of PHI
• Other uses and disclosures not described in this notice

You may revoke your authorization at any time in writing, except to the extent that we have already acted on it.

Your Rights Regarding Your PHI

Right to Inspect and Copy

You have the right to inspect and copy your PHI that we maintain, with limited exceptions. To request access, submit a written request to our Privacy Officer. We may charge a reasonable fee for copies.

Right to Amend

If you believe the PHI we have about you is incorrect or incomplete, you may request that we amend it. We may deny your request under certain circumstances.

Right to an Accounting of Disclosures

You have the right to request a list of certain disclosures of your PHI we have made in the six years prior to the date of your request.

Right to Request Restrictions

You have the right to request restrictions on how we use or disclose your PHI for treatment, payment, or healthcare operations. We are not required to agree to your request except as required by law.

Right to Request Confidential Communications

You have the right to request that we communicate with you about your PHI in a certain way or at a certain location (e.g., only by phone, only at your work address).

Right to a Paper Copy of This Notice

You have the right to receive a paper copy of this notice at any time, even if you have agreed to receive it electronically. Please contact us to request one.

Changes to This Notice

We reserve the right to change the terms of this notice and to make any new provisions effective for all PHI we maintain. We will post a current copy of this notice on our website and make it available at our pharmacy. The revised notice will include the effective date.

Complaints

If you believe your privacy rights have been violated, you may file a complaint with us or with the U.S. Department of Health and Human Services Office for Civil Rights. We will not retaliate against you for filing a complaint.

To file a complaint with HHS: www.hhs.gov/hipaa/filing-a-complaint

Contact Our Privacy Officer

For questions about this notice or to exercise your rights, contact: