Privacy Policy & Disclaimer

IMPACT COMPOUNDING
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.

Dear Patient:

Impact Compounding LLC, an Ohio limited liability company licensed to practice pharmacy (“we”, “us”, “our”, or “Pharmacy”), understands that Patient (“you”, “your”) privacy is important. This Notice of Privacy Practices (“Notice”) applies to the Pharmacy and each of our Business Associates, as applicable.

PROTECTED HEALTH INFORMATION

Protected health information (“PHI”) relates to information about you and your health, which could be used to identify you. Each time that you visit us, we create a medical record of your PHI and services that you receive.

OUR OBLIGATION REGARDING YOUR PROTECTED HEALTH INFORMATION

We recognize that information about you and your health is confidential, and we are committed to protecting this information. This Notice applies to all your health records that we create.

We are required by law to preserve the privacy and security of your PHI. While there is no absolute guarantee of privacy, we are committed to protecting your privacy. We have established reasonable and appropriate measures to protect your PHI against unauthorized uses and disclosures.

Federal law mandates that we share this Notice with you, and that we make a good-faith effort to obtain a signed document acknowledging your receipt of this Notice. We are also required to follow the terms of this Notice. If we are involved in a breach of your PHI, we will immediately notify you.

NOTICE EFFECTIVE DATE AND POTENTIAL CHANGES

This Notice became effective on May 1, 2023, and it applies to health records that we create for you. We reserve the right to change this Notice after the effective date. We can change the terms of this Notice, and the changes will apply to all the information we have about you. The new Notice will be available upon request.

HOW WE MAY DISCLOSE YOUR PROTECTED HEALTH INFORMATION

The laws of the state where Pharmacy is located, and federal laws, allow disclosures of your PHI in some cases. Some of these disclosures do not require your verbal or written permission. The following information describes how we may share your PHI. We may typically use or share your PHI in these ways:

TREAT YOU

We can use your PHI and share it with other professionals who are treating you.

• Example: A doctor treating you for a condition and asks another doctor about your overall health condition.

RUN OUR ORGANIZATION

We can use and share your PHI to run our pharmacy, improve your care, and contact you when necessary.

• Example: We use health information about you to manage your treatment and services.

BILL FOR YOUR SERVICES

We can use and share your PHI to bill and obtain payment from health plans or other entities.

• Example: We give information about you to your health insurance plan so it will potentially pay for your services. *We do not directly bill your insurance.

HELP WITH PUBLIC HEALTH AND SAFETY ISSUES

We can share your PHI for certain situations such as

• Preventing disease;
• Helping with product recalls;
• Reporting adverse reactions to medications;
• Reporting suspected abuse, neglect, or domestic violence; and
• Preventing or reducing a serious threat to anyone’s health or safety.

PERFORM RESEARCH

We can use or share your PHI for health research.

COMPLY WITH THE LAW

We will share your PHI if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we are complying with federal privacy law.

RESPOND TO ORGAN AND TISSUE DONATION REQUESTS

We can share your PHI with organ procurement organizations.
Work with a medical examiner or funeral director.
We can share your PHI with a coroner, medical examiner, or funeral director when an individual dies.

ADDRESS OTHER GOVERNMENT REQUESTS
We can use or share your PHI:

• For workers’ compensation claims;
• For law enforcement purposes or with a law enforcement official;
• With health oversight agencies for activities authorized by law; and
• For special government functions such as military, national security, and presidential protective services.

RESPOND TO ORGAN AND TISSUE DONATION REQUESTS

We can share your PHI in response to a court or administrative order, or in response to a subpoena.

HOW ELSE CAN WE USE OR SHARE YOUR PHI?

We are allowed or required to share your PHI in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. We have not listed every use and disclosure in this Notice. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.

USE AND DISCLOSURE OF YOUR PHI WITH YOUR VERBAL AGREEMENT

For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.

In these cases, you have both the right and choice to tell us to:

• Share information with your family, close friends, or others involved in your care;
• Share information in a disaster relief situation; and
• Include your information in a hospital directory.

If you cannot tell us your preference, for example, if you are unconscious, we may share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.

USE AND DISCLOSURE OF YOUR PHI REQUIRING YOUR WRITTEN PERMISSION

If there are situations that have not been described above, we will obtain your written permission. In these cases, we never share your PHI unless you give us written permission:

• Marketing purposes;
• Sale of your information; and
• Most sharing of psychotherapy notes.

With fundraising, we may contact you for fundraising efforts, but you can tell us not to contact you again.

If you provide us with written permission, you may change your mind at any time. Please let us know in writing if you change your mind.

YOUR RIGHTS REGARDING YOUR PHI

You have the following rights regarding your PHI that is created in our pharmacy. This section explains some of your rights and our responsibilities to assist you.

GET AN ELECTRONIC OR PAPER COPY OF YOUR MEDICAL RECORD

• You can ask to see or receive an electronic or paper copy of your medical record and other PHI that we have about you. Ask us how to do this.
• We will provide a copy or a summary of your PHI, usually within 30 days of your request. We may charge a reasonable cost-based fee.

ASK US TO CORRECT YOUR MEDICAL RECORD

• You can ask us to correct PHI about you that you think is incorrect or incomplete. Ask us how to do this.
• We may say “no” to your request, but we will tell you why in writing within 60 days.

REQUEST CONFIDENTIAL COMMUNICATIONS

• You can ask us to contact you in a specific way (for example, home or office phone), or to send mail to a different address.
• We will say “yes” to all reasonable requests.

ASK US TO LIMIT WHAT WE USE OR SHARE

• You can ask us not to use or share certain PHI in connection with our services.
• We are not required to agree to your request, and we may say “no” if it would affect your care.
• Because you are privately paying for some medical or health services, you may ask us to refrain from sharing information related to those private pay services with your health insurance plan. We will respect that request unless we are legally obligated otherwise under applicable laws.

GET A LIST OF WHO WE HAVE SHARED INFORMATION

• You can ask for a list (accounting) of the times we have shared your PHI for six years prior to the date you ask, who we shared it with, and why.
• We will include all the disclosures except for those about treatment, health care operations, and certain other disclosures (such as any you asked us to make).
• We will provide one accounting per year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.

GET A COPY OF THIS NOTICE

• You can ask for a paper copy of this Notice at any time, even if you have agreed to receive this Notice electronically. We will provide you with a paper copy promptly.

CHOOSE SOMEONE TO ACT FOR YOU

• If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.
• We will make sure the person has this authority and can act for you before we take any action.

ASK QUESTIONS TO FILE A COMPLAINT IF YOU BELIEVE YOUR RIGHTS ARE VIOLATED

If you have questions about this Notice or you believe that your rights are being violated, please contact us immediately:

PHARMACY CONTACT INFORMATION:

Impact Compounding, LLC
Attention: Dawn Trame, RPh
1920 Donn Davis Way, Tipp City, OH 45371
email: info@impactcompounding.com
tel: 937-761-2606

You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints.

Please provide as much information as possible so that the Department of Health and Human Services can thoroughly investigate your concern or complaint. We will not retaliate against you for filing a complaint with us, or the Department of Health and Human Services.

Thank you,

Impact Compounding

IMPACT COMPOUNDING
ELECTRONIC COMMUNICATIONS AGREEMENT

Impact Compounding, LLC, an Ohio limited liability company licensed to practice pharmacy and related services (“we”, “us”, or “Pharmacy”) and the undersigned patient (“Patient”) enter into this Electronic Communications Agreement (“EC Agreement”) regarding the use of e-communications/transmissions, such as email, mobile or cellular telephone, Skype, FaceTime, internet portal-enabled communications, or any other version of electronic communication (collectively “E-Communication”) with respect to Patient protected health information (“PHI”). (Pharmacy and Patient are each individually called “Party” or collectively as “Parties”).

PATIENT AUTHORIZATION DESPITE RISKS OF PRIVACY BREACH

While Pharmacy and Patient commonly rely on electronic communication platforms and services to achieve communication immediacy, there are risks that Patient acknowledges that are outside the control of the Pharmacy. Patient authorizes all forms of E-Communications that the Parties exchange between each other unless Patient instructs us otherwise in writing. Patient acknowledge that the use of E-Communication is inherently risky and prone to unintentional release of data. E-Communications may incorporate or communicate references to Patient’s PHI with sensitive health and personal identification information included. Patient acknowledges that E-Communications lack any absolute guaranty of privacy and are subject to: system privacy failure, cookies and other tracking efforts, phishing attacks, hacking attacks, data breaches, unintended misdirections, misidentifications of senders/recipients, technology failures, and user errors.

Patient agrees to undertake efforts to protect Patient’s privacy, which includes refraining from including sensitive information in E-Communications that Patient does not want to be at risk of any data security breach. Pharmacy will undertake reasonable efforts to protect Patient’s privacy to the extent required by applicable laws. Patient authorizes us to respond electronically to all E-Communications that appear to be provided by Patient, whether or not such communications arrive from the electronic contact information that Patient provides us.

PATIENT MUST PROVIDE ACCURATE AND UPDATED CONTACT INFORMATION

Patient agrees to provide us with Patient’s accurate electronic contact information (mobile telephone number for phone calls and text messaging, email address, Skype or FaceTime contact information, and any other applicable E-Communication contact information). Patient will immediately inform us of any changes or corrections to Patient’s electronic contact information as an effort to avoid misdirected E-Communications.

PATIENT MUST NOT RELY ON ELECTRONIC COMMUNICATION IN EMERGENCIES: USE 911 AND GET TO THE EMERGENCY ROOM

Impact Compounding does not guarantee that we will read Patient’s E-Communications immediately or within any specific amount of time. Patient agrees not to utilize E-Communications to contact us about an emergency or time- sensitive situation, as there is too much risk that the communication response may be delayed, ineffective, untimely, or inadequate. Patient MUST call 911 in an emergency, immediately seek emergency medical attention, or both.

PHARMACY WILL COMPLY WITH HIPAA

The Pharmacy values and appreciates Patient’s privacy and will take commercially reasonable steps to protect Patient’s privacy in compliance with the Health Insurance Portability and Accountability Act of 1996 and related laws (“HIPAA”).

We will obtain Patient’s express written or electronic consent (to the extent required by applicable law) if we are required or requested to forward Patient’s identifiable PHI to any third-party other than as authorized in our Notice of Privacy Practices or as authorized or mandated by applicable law.

Patient hereby consents to the use of E-Communication of Patient’s information as we consider it helpful to coordinate care and schedule mobile visits with Patient and all those responsible for providing or overseeing Patient’s care. Patient agrees to identify individuals or entities authorized to receive Patient’s PHI from us in connection with authorized consulting, education, and all other aspects of Patient’s care, and we may share Patient’s PHI with such parties without additional written or electronic consent from Patient.

Patient has the right to ask us for a copy of Patient’s PHI, including an explanation or summary. These services that we perform will not be the subject of additional charges to Patient: maintaining PHI storage systems, recouping capital or expenses for PHI data access, PHI storage, and infrastructure, or retrieval of PHI electronic information.

We may charge Patient fees for actual costs that we incur to provide such electronic PHI, but only to the extent authorized by applicable laws. Such fees may include to the extent lawful: skilled technical staff time spent to create and copy PHI; compiling, extracting, scanning, and burning PHI to media and distributing the media with media costs charged to Patient; and time spent by our administrative staff preparing more explanations or summaries of PHI. If Patient requests PHI on a paper copy, or portable media (such as compact disc/CD, or universal serial bus/USB flash drive), we may charge Patient for our actual supply costs for such equipment, and Patient agrees to pay us any such costs.

PATIENT ACCEPTS RESPONSIBILITY FOR ELECTRONIC COMMUNICATION RISKS

Patient will hold Pharmacy (and our owners, officers, directors, agents, and employees) harmless from and against any and all demands, claims, and damages to persons or property, losses, and liabilities, including reasonable attorney fees, arising out of or caused by E-Communication (whether encrypted or not) losses or disclosures caused by any of the risks outlined above, or caused by some person or entity other than Pharmacy, or not directly caused by us. Patient acknowledges and understands that, at our discretion, E- Communication may or may not become part of Patient’s permanent medical record. These terms do not relieve Pharmacy from Pharmacy’s obligations to comply with all applicable E-Communication laws.

Patient acknowledges that Patient’s failure to comply with the terms of this EC Agreement may lead to our terminating the use of E-Communication methods with Patient and may cause the termination of Patient’s agreement for our services.

ADDITIONAL TERMS

This EC Agreement will remain in effect until either Party provides written notice to the other Party revoking this EC Agreement or otherwise revoking consent to E-Communications between the Parties. Such revocation will occur thirty (30) calendar days after written notice of such revocation.

Revocation of this EC Agreement will preclude us from providing treatment information in an electronic format other than as authorized or mandated by applicable law or by Patient. Either Party may use a copy of this signed original EC Agreement for all present and future purposes.

Parties agree to take such action as is reasonably necessary to amend this EC Agreement from time to time as it is necessary for the Parties to comply with the requirements of the Privacy Rule, the Security Rule, and other provisions of HIPAA, or other applicable law. Parties also agree that no one can change, modify, or discharge this EC Agreement unless both Parties write and sign a separate agreement to change the EC Agreement.

If any term of this EC Agreement is found invalid or in violation of any applicable law or public policy, the remaining terms of this EC Agreement shall govern, and this EC Agreement shall be deemed amended to conform to any applicable law.

Each participating patient (and authorized representative when applicable) must sign this EC Agreement. Patient’s signature represents that Patient understands and agrees to the terms and conditions described within this EC Agreement. To allow an additional authorized representative please contact us at info@impactcompounding.com.

PHARMACY:
IMPACT COMPOUNDING, LLC
AN OHIO LIMITED LIABILITY COMPANY

Dawn Trame, RPh/ Title: Head Pharmacist/ Effective Date: 05/01/2023

Prior to acknowledgement of this form review information our website both under the drug information sheets and regarding hormones and testing. If you have further questions/concerns or need further clarification, please contact us at (937)761-2606. https://impactcompounding.com
https://impactcompounding.com/documents/

I have been informed that Impact Compounding does not bill insurance for pharmacist or physician evaluation, medications and/or laboratory testing. I agree to pay for all services and pharmacy charges, with the understanding that I may not be reimbursed by my insurance company should I submit a universal claim form. I also understand that all hormone test kit sales are final and non-refundable.

The benefits of any treatment or therapies including the risks and potential complications have been explained to me as well as the potential risks of not being treated. Impact Compounding has not been promised or guaranteed any specific benefit from the administration of these therapies and no warranty or guarantee has been made regarding the results of treatment. I agree to proceed with treatment and to comply with recommended dosages.

I agree to see my primary care physician, gynecologist, or other practitioner for regular monitoring and for preventative measures (physicals, rectal examinations and/or colonoscopy, EKG, mammograms, pelvic/breast exams, pap smears, prostate exams, PSA levels, etc.). I agree to comply with requests for ongoing testing to assure proper monitoring of my treatments that may include laboratory evaluation of all hormone levels or other diagnostic testing by a physician, my primary care physician, or other specialist. I agree to immediately report to my physician any adverse reaction or problem that might be related to my therapy.

I certify this form has been fully explained to me and that I have read and understood it. I have been educated on the benefits, risks, and possible adverse reactions associated with bio-identical hormone replacement therapy. I have been given the opportunity to access information, ask any questions and have had them answered to my satisfaction. I agree not to undergo any treatments unless I fully understand the treatment and have discussed possible risks and benefits. I fully understand what I am agreeing to and hereby request and consent to treatment at Impact Compounding using bioidentical hormone replacement therapy.