Mycelium Pharmacy
NOTICE OF PRIVACY PRACTICES
Effective November 1,2020
As part of the federal Health Insurance Portability and Accountability Act of 1996, known as HIPAA,
the healthcare provider has created this Notice of Privacy Practices (Notice). This Notice describes
the healthcare provider’s privacy practices and the rights you, the individual, have as they relate to
the privacy of your Protected Health Information (PHI). Your PHI is information about you, or that
could be used to identify you, as it relates to your past and present physical and mental health care
services. The HIPAA regulations require that the healthcare provider protect the privacy of your
PHI that the healthcare provider has received or created.
This healthcare provider will abide by the terms presented within this Notice. For any uses or
disclosures that are not listed below, the healthcare provider will obtain a written authorization
from you for that use or disclosure, which you will have the right to revoke at any time, as explained
in more detail below. The healthcare provider reserves the right to change the healthcare
provider’s privacy practices and this Notice. Revisions to the Notice will be posted in the
healthcare provider and upon your request, provided to you in a paper format.
HOW THE HEALTHCARE PROVIDER MAY USE AND DISCLOSE YOUR PHI
The following is an accounting of the ways that the healthcare provider is permitted, by law, to use
and disclose your PHI.
Uses and disclosures of PHI for Treatment: We will use the PHI that we receive from you to fill
your prescription and coordinate or manage your health care.
Uses and disclosures of PHI for Payment: The healthcare provider will disclose your PHI to
obtain payment or reimbursement from insurers for your health care services.
Uses and disclosures of PHI for Health Care Operations: The healthcare provider may use the
minimum necessary amount of your PHI to conduct quality assessments, improvement activities,
and evaluate the healthcare provider workforce.
The following is an accounting of additional ways in which the healthcare provider is permitted or
required to use or disclose PHI about you without your written authorization. All uses and
disclosures will be to the minimum necessary amount of your PHI. Many of these uses and
disclosures will never be made by the healthcare provider; however, we are required by law to
notify you of them as a health care provider.
Uses and disclosures as required by law: The healthcare provider is required to use or disclose
PHI about you as required and as limited by law.
Uses and disclosure for Public Health Activities: The healthcare provider may use or disclose
PHI about you to a public health authority that is authorized by law to collect for the purpose of
preventing or controlling disease, injury, or disability. This includes the FDA so that it may monitor
any adverse effects of drugs, foods, nutritional supplements and other products as required by law.
Uses and disclosure about victims of abuse, neglect or domestic violence: The healthcare
provider may use or disclose PHI about you to a government authority if it is reasonably believed you
are a victim of abuse, neglect or domestic violence.
Uses and disclosures for health oversight activities: The healthcare provider may use or disclose
PHI about you to a health oversight agency for oversight activities which may include audits,
investigations, inspections as necessary for licensure, compliance with civil laws, or other activities
the health oversight agency is authorized by law to conduct.
Disclosures for judicial and administrative proceedings: The healthcare provider may disclose
PHI about you in the course of any judicial or administrative proceedings, provided that proper
documentation is presented to the healthcare provider.
Disclosures for law enforcement purposes: The healthcare provider may disclose PHI about you
to law enforcement officials for authorized purposes as required by law or in response to a court
order or subpoena.
Uses and disclosures about the deceased: The healthcare provider may disclose PHI about a
deceased, or prior to, and in reasonable anticipation of an individual’s death, to coroners, medical
examiners, and funeral directors.
Uses and disclosures for cadaveric organ, eye or tissue donation purposes: The healthcare
provider may use and disclose PHI for the purpose of procurement, banking, or transplantation of
cadaveric organs, eyes, or tissues for donation purposes.
Uses and disclosures for research purposes: The healthcare provider may use and disclose PHI
about you for research purposes with a valid waiver of authorization approved by an institutional
review board or a privacy board. Otherwise, the healthcare provider will request a signed
authorization by the individual for all other research purposes.
Uses and disclosures to avert a serious threat to health or safety: The healthcare provider may
use or disclose PHI about you, if it is believed in good faith, and is consistent with any applicable law
and standards of ethical conduct, to avert a serious threat to health or safety.
Uses and disclosures for specialized government functions: The healthcare provider may use or
disclose PHI about you for specialized government functions including; military and veteran’s
activities, national security and intelligence, protective services, department of state functions, and
correctional institutions and law enforcement custodial situations.
Disclosure for workers’ compensation: The healthcare provider may disclose PHI about you as
authorized by and to the extent necessary to comply with workers’ compensation laws or programs
established by law.
Disclosures for disaster relief purposes: The healthcare provider may disclose PHI about you as
authorized by law to a public or private entity to assist in disaster relief efforts.
Disclosures to business associates: The healthcare provider may disclose PHI about you to the
healthcare provider’s business associates for services that they may provide to or for the healthcare
provider to assist the healthcare provider to provide quality health care. To ensure the privacy of
your PHI, we require all business associates to apply appropriate safeguards to any PHI they receive
or create.
OTHER USES AND DISCLOSURES
The healthcare provider may contact you for the following purposes:
Refill reminders: The healthcare provider may contact you to remind you of your prescription
upon such time they are ready to be refilled.
Information about treatment alternatives: The healthcare provider may contact you to notify
you of alternative treatments and/or products.
Health related benefits or services: The healthcare provider may use your PHI to notify you of
benefits and services the healthcare provider provides.
Fundraising: If the healthcare provider participates in a fundraising activity, the healthcare
provider may use demographic PHI to send you a fundraising packet, or the healthcare provider
may disclose demographic PHI about you to its business associate or an institutionally related
foundation to send you a fundraising packet. No further disclosure will be allowed by the business
associates or an institutionally related foundation without your written authorization
FOR ALL OTHER USES AND DISCLOSURES
The healthcare provider will obtain a written authorization from you for all other uses and
disclosures of PHI, and the healthcare provider will only use or disclose pursuant to such an
authorization. In addition, you may revoke such an authorization in writing at any time. To revoke
a previously authorized use or disclosure, please contact Mycelium Pharmacy to obtain a Request
for Restriction of Uses and Disclosures.
YOUR HEALTH INFORMATION RIGHTS
The following are a list of your rights in respect to your PHI.
Request restrictions on certain uses and disclosures of your PHI: You have the right to request
additional restrictions of the healthcare provider’s uses and disclosures of your PHI; however, the
healthcare provider is not required to accommodate a request. If you wish to request additional
restrictions, please obtain the form, Request for Restriction of Uses & Disclosures, from the
healthcare provider and return the completed form to the healthcare provider or return to
Mycelium Pharmacy.
The right to have your PHI communicated to you by alternate means or locations: You have
the right to request that the healthcare provider communicate confidentially with you using an
address or phone number other than your residence. However, state and federal laws require the
healthcare provider to have an accurate address and home phone number in case of emergencies.
The healthcare provider will consider all reasonable requests. If you wish to request a change in
your communicating address and/or phone number, please obtain a form, Request for Alternative
Arrangements for Confidential Communication, from the healthcare provider and return the
completed form to the healthcare provider or return to Mycelium Pharmacy.
The right to inspect and/or obtain a copy of your PHI: You have the right to request access
and/or obtain a copy of your PHI that is contained in the healthcare provider for the duration the
healthcare provider maintains PHI about you. If you wish to inspect or obtain a copy of your PHI,
please obtain a form, Request for Access to Records, from the healthcare provider and return the
completed form to the healthcare provider or return to Mycelium Pharmacy. There may be a
reasonable cost-based charge for photocopying documents. You will be notified in advance of
incurring such charges, if any.
The right to amend your PHI: You have the right to request an amendment of the PHI the healthcare
provider maintains about you, if you feel that the PHI the healthcare provider has maintained about
you is incorrect or otherwise incomplete. Under certain circumstances we may deny your request
for amendment. If we do deny the request, you will have the right to have the denial reviewed by
someone we designate who was not involved in the initial review. You may also ask the Secretary,
United States Department of Health and Human Services (“HHS”), or their appropriate designee, to
review such a denial. If you wish to amend your PHI files, please obtain a form, Request for
Amendment to PHI, from the healthcare provider and return the completed form to the healthcare
provider or return to Mycelium Pharmacy.
The right to receive an accounting of disclosures of your PHI: You have the right to receive an
accounting of certain disclosures of your PHI made by the healthcare provider. If you wish to receive
an accounting of disclosures of your PHI, please obtain a form, Request for Accounting of Disclosures,
from the healthcare provider and return the completed form to the healthcare provider or return to
Mycelium Pharmacy. You should be aware, however, that such an accounting excludes uses and
disclosures made for treatment, payment, or health care operations purposes.
The right to receive additional copies of the Healthcare Provider’s Notice of Privacy Practices:
You have the right to receive additional paper copies of this Notice, upon request, even if you initially
agreed to receive the Notice electronically. If you wish to receive a paper copy of this request, please
ask a healthcare provider workforce member and they will provide you with a copy.
REVISIONS TO THE NOTICE OF PRIVACY PRACTICES
The healthcare provider reserves the right to change and/or revise this Notice and make the new
revised version applicable to all PHI received prior to its effective date. The revised Notice will be
available, upon request, to all individuals. The healthcare provider will also post the revised version
of the Notice in the healthcare provider.
COMPLAINTS
If you believe your privacy rights have been violated, you may file a complaint with the healthcare
provider and/or to the Secretary of HHS, or his designee. If you wish to file a complaint with the
healthcare provider, please contact Mycelium Pharmacy. If you wish to file a complaint with the
Secretary, please write to:
Office for Civil Rights
Sam Nunn Atlanta Federal Center (SNAFC)
61 Forsyth Street, SW
Atlanta, GA 30303-8909
The healthcare provider will not take any adverse action against you as a result of your filing of a
complaint.
CONTACT INFORMATION
If you have any questions on the healthcare provider’s privacy practices or for clarification on
anything contained within the Notice, please contact:
Mycelium Pharmacy
Momina Karapetyan, Privacy Officer
141 E Commercial Blvd
Ft Lauderdale, FL 33334
954-890-1150
