CONFIDENTIALITY AND NOTICE OF PRIVACY PRACTICES ACKNOWLEDGMENT
I acknowledge that I have been given the opportunity to read the Notice of Privacy Practices (NOPP) of Conway's Eastside Pharmacy, posted in the pharmacy or have been given my own copy. I acknowledge that I agree with the patient authorization information provided above.
I understand that Conway's Eastside Pharmacy, through its HIPAA policies is obligated to protect my confidental personal health information. I have the right to request to see their HIPAA policies at any time. Conway's Eastside Pharmacy reserves the right to change the terms of its Privacy Notice. If such changes are made, I understand that the Privacy Notice will be posted on the CEP website and I can request a copy at any time.
I understand that I am responsible to provide current and accurate insurance information to Conway's Eastside Pharmacy and a copy of their current insurance card. I also understand that a delay in getting current and accurate insurance information to the pharmacy will result in a delay in getting my prescriptions. I understand that I may also get an option to pay out-of-pocket for prescription(s) if I cannot obtain current and accurate insurance informationin a timely manner.
I verify by my signature below that I give permission for prescription(s), over-the-counter item(s) and delivery services; I have been informed of my privacy rights; I am responsible for charges on my credit card and authorize of my health informtion to process any insurance claims.