PATIENT AUTHORIZATION PLAN OF CARE / SERVICE

Insurance payment authorization: I request that Medicare and/or any other insurance plan that I have to make payments of authorized benefits on my behalf directly to Hometown Specialty for pharmaceuticals/equipment/supplies that were furnished to me for which they bill Medicare and/or any other insurance plan on my behalf. Release of insurance information: I request my medical insurance plan(s) to release to the above-named company, any and all information which will assist in processing my claims for pharmaceuticals, equipment and/or medical supplies that I am receiving from the above-named company even after service to me is discontinued. I also authorized any holder of hospital or medical information about me to release to the healthcare financing administration, its agents, my insurance company or the above-named company any information needed to determine the benefits that are payable for related services. I understand if my insurance plan(s) makes payment(s) to me for pharmaceuticals, equipment and/or medical supplies that I have received, rather than directly to the above-named company, I agree to endorse those checks and send them immediately to the above-named company. I also understand that I am responsible for the payment of any deductible, co-insurance or other portion of my charges not paid by my insurance plan(s I also understand that I may be eligible for a partial or complete waiver of any unpaid co-insurance charges only, under Hometown Specialty Pharmacy financial hardship program. (Initials) I acknowledge that I have been advised of my financial obligations to Hometown Specialty Pharmacy including co-pays, deductibles and any anticipated denials for products furnished by Hometown Specialty Pharmacy. I hereby agree that Hometown Specialty Pharmacy or any of its affiliates may contact me at my place of residence or cellular telephone, my authorized caregiver and/or emergency contact by telephone. I agree to enter into the patient management program at Hometown Specialty Pharmacy. I have reviewed and understand the information above. I have been instructed on and understand the use of the products provided. I have received a copy of a patient handout that contains a welcome letter, patient rights and responsibilities, information on access to pharmacy services, HIPAA privacy notice, emergency planning, making decisions about your healthcare, grievance/complaint information and drug safety and disposal techniques. I have received the medication monograph/drug education information and, if applicable, equipment and medical supply instructions, warranty information. I have received instructions on how to contact Hometown Specialty Pharmacy.

I understand that prescribed medications cannot be re-dispensed. By law, these items cannot be returned for credit.

I understand the limitations of the patient management program, including that they do not supplant physician advice or interactions and are subject to my compliance and willingness to participate. I understand that I may lodge a complaint without concern for reprisal, discrimination, or unreasonable interruption of service with the pharmacy directly at 270-937-9008.

Identified needs/problems: I understand I may be unfamiliar with use of the medications, equipment and/or medical supplies provided. Expected outcomes: The patient will receive education on prescribed therapy, pharmaceutical medication guide, first dose counseling and administration teaching prior to being provided the pharmaceuticals, equipment and/or medical supplies to comply with the prescriber's prescription. I will use the medication(s), equipment and/or medical supplies to comply with the prescriber's prescription. I will use the medication(s), equipment and/or medical supplies as prescribed. I will know how to obtain follow-up services as needed.

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.

It is our duty to maintain the privacy and confidentiality of your protected health information (PHI We will create records regarding your and the treatment and service we provide to you. We are required by law to maintain the privacy of your PHI, which includes any individually identifiable information that we obtain from you or others that relates to your past, present or future physical or mental health, the health care you have received, or payment for your health care. We will share protected health information with one another, as necessary, to carry out treatment, payment or health care operations relating to the services to be rendered at the company. As required by law, this notice provides you with information about your rights and our legal duties and privacy practices with respect to the privacy of PHI. This notice also discusses the uses and disclosures we will make of your PHI. We must comply with the provisions of this notice as currently in effect, although we reserve the right to change the terms of this notice from time to time and to make the revised notice effective for all PHI we maintain. You can always request a written copy of our most current privacy notice from our Privacy Officer.

We can use or disclose your PHI for purposes of treatment, payment and health care operations. For each of these categories of uses and disclosures, we have provided a description and an example below. However, not every particular use or disclosure in every category will be listed. Treatment means providing services as ordered by your prescriber. Treatment also includes coordination and consultations with other health care providers relating to your care and referrals for health care from one health care provider to another. We may also disclose PHI to outside entities performing other services related to your treatment such as hospitals, diagnostic laboratories, home health or hospice agencies, etc.

Payment means the activities we undertake to obtain reimbursement for the health care provided to you, including billing, collections, claims management, prior approval, determinations of eligibility and coverage and other utilization review activities. Federal or state law may require us to obtain a written release from you prior to disclosing certain specially protected PHI for payment purposes, and we will ask you to sign a release, when necessary, under applicable law. Health care operations means the support functions of the company, related to treatment and payment, such as quality assurance activities, case management, receiving and responding to patient comments and complaints, physician reviews, compliance programs, audits, business planning, development, management, and administrative activities. We may use your PHI to evaluate the performance of our staff when caring for you. We may also combine PHI about many patients to decide what additional services we should offer, what services are not needed, and whether certain new treatments are effective. We may also disclose PHI for review and learning purposes. In addition, we may remove information that identifies you SO that others can use the de-identified information to study health care and health care delivery without learning who you are.

OTHER USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION

We may also use your PHI in the following ways: To provide appointment reminders for treatment or medical care. To tell you about or recommend possible treatment alternatives or other health-related benefits and services that may be of interest to you. To disclose to your family or friends or any other individual identified by you to the extent directly related to such person's involvement in your care or the payment for your care. We may use or disclose your PHI to notify, or assist in the notification of, a family member, a personal representative, or another person responsible for your care, of your location, general condition, or death. When permitted by law, we may coordinate our uses and disclosures of PHI with public or private entities authorized by law or by charter to assist in disaster relief efforts. We will allow your family, provider(s) and friends to act on your behalf to pick up filled prescriptions, medical supplies, and similar forms of PHI, when we determine, in our professional judgment, that it is in your best interest to make such disclosures. We may contact you as part of our fundraising and marketing efforts as permitted by applicable law. You have the right to opt out of receiving such fundraising communications. We may use or disclose your PHI for research purposes, subject to the requirements of applicable law. For example, a research project may involve comparisons of the health and recovery of all patients who received a particular medication. All research projects are subject to a special approval process which balances research needs with a patient's need for privacy. When required, we will obtain a written authorization from you prior to using your health information for research. We will use or disclose PHI about you when required to do SO by applicable law. In accordance with applicable law, we may disclose your PHI to your employer if we are retained to conduct an evaluation relating to medical surveillance of your workplace or to evaluate whether you have a work-related illness or injury. You will be notified of these disclosures by your employer or the company as required by applicable law. Note: incidental uses and disclosures of PHI sometimes occur and are not considered to be a violation of your rights. Incidental uses and disclosures are by-products of otherwise permitted uses or disclosures which are limited in nature and cannot be reasonably prevented.

Subject to the requirements of applicable law, we will make the following uses and disclosures of your

Organ and Tissue Donation. If you are an organ donor, we may release PHI to organizations that handle organ procurement or transplantation as necessary to facilitate organ or tissue donation and transplantation.

Military and Veterans. If you are a member of the Armed Forces, we may release PHI about you as required by military command authorities. We may also release PHI about foreign military personnel to the appropriate foreign military authority.

Workers' Compensation. We may release PHI about you for programs that provide benefits for work related injuries or illnesses. 

Public Health Activities. We may disclose PHI about you for public health activities, including disclosures:

• to prevent or control disease, injury or disability;
• to report births and deaths;
• to report child abuse or neglect;
• to persons subject to the jurisdiction of the Food and Drug Administration (FDA) for activities related to the quality, safety, or effectiveness of FDA-regulated products or services and to report reactions to medications or problems with products;
• to notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition; to notify the appropriate government authority if we believe that an adult patient has been the victim of abuse, neglect or domestic violence. We will only make this disclosure if the patient agrees or when required or authorized by law. Health Oversight Activities. We may disclose PHI to federal or state agencies that oversee our activities (e.g., providing health care, seeking payment, and civil rights Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, we may disclose PHI subject to certain limitations. Law Enforcement. We may release PHI if asked to do SO by a law enforcement official:
• in response to a court order, warrant, summons or similar process;
• to identify or locate a suspect, fugitive, material witness, or missing person;
• about the victim of a crime under certain limited circumstances;
• about a death we believe may be the result of criminal conduct;
• about criminal conduct on our premises; or
• in emergency circumstances, to report a crime, the location of the crime or the victims, or the identity, description or location of the person who committed the crime. Coroners, Medical Examiners and Funeral Directors.

We may release PHI to a coroner or medical examiner. We may also release PHI about patients to funeral directors as necessary to carry out their duties. 

National Security and Intelligence Activities. We may release PHI about you to authorized federal officials for intelligence, counterintelligence, other national security activities authorized by law or to authorized federal officials SO they may provide protection to the President or foreign heads of state. Inmates. If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release PHI about you to the correctional institution or law enforcement official. This release would be necessary (1) to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) for the safety and security of the correctional institution. Serious Threats. As permitted by applicable law and standards of ethical conduct, we may use and disclose PHI if we, in good faith, believe that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public or is necessary for law enforcement authorities to identify or apprehend an individual. Note: HIV-related information, genetic information, alcohol and/or substance abuse records, mental health records and other specially protected health information may enjoy certain special confidentiality protections under applicable state and federal law. Any disclosures of these types of records will be subject to these special protections.

OTHER USES OF YOUR HEALTH INFORMATION

Certain uses and disclosures of PHI will be made only with your written authorization, including uses and/or disclosures: (a) psychotherapy notes (where appropriate); (b) for marketing purposes; and (c) that constitute a sale of PHI under the Privacy Rule. Other uses and disclosures of PHI not covered by this notice or the laws that apply to us will be made only with your written authorization. You have the right to revoke that authorization at any time, provided that the revocation is in writing, except to the extent that we already have taken action in reliance on your authorization.

YOUR RIGHTS

You have the right to request restrictions on our uses and disclosures of PHI for treatment, payment and healthcare operations. However, we are not required to agree to your request unless the disclosure is to a health plan in order to receive payment, the PHI pertains solely to your health care items or services for which you have paid the bill in full, and the disclosure is not otherwise required by law. To request a restriction, you may make your request in writing to the Privacy Officer. You have the right to reasonably request to receive confidential communications of your PHI by alternative means or at alternative locations. To make such a request, you may submit your request in writing.

You have the right to inspect and copy the PHI contained in our company records, except:

• for psychotherapy notes, (i.e., notes that have been recorded by a mental health professional documenting counseling sessions and have been separated from the rest of your medical record); information compiled in reasonable anticipation of, or for use in, a civil, criminal, or administrative action or proceeding;
• for PHI involving laboratory tests when your access is restricted by law; 
• if you are a prison inmate, and access would jeopardize your health, safety, security, custody, or rehabilitation or that of other inmates, any officer, employee, or other person at the correctional institution or person responsible for transporting you;
• if we obtained or created PHI as part of a research study, your access to the PHI may be restricted for as long as the research is in progress, provided that you agreed to the temporary denial of access when consenting to participate in the research;
• for PHI contained in records kept by a federal agency or contractor when your access is restricted by law; and for PHI obtained from someone other than us under a promise of confidentiality when the

access requested would be reasonably likely to reveal the source of the information.

• In order to inspect or obtain a copy your PHI, you may submit your request in writing to the Privacy Officer. If you request a copy, we may charge you a fee for the costs of copying and mailing your records, as well as other costs associated with your request. We may also deny a request for access to PHI under certain circumstances if there is a potential for harm to yourself or others. If we deny a request for access for this purpose, you have the right to have our denial reviewed in accordance with the requirements of applicable law. You have the right to request an amendment to your PHI but we may deny your request for amendment, if we determine that the PHI or record that is the subject of the request:
• was not created by us, unless you provide a reasonable basis to believe that the originator of PHI is no longer available to act on the requested amendment;
• is not part of your medical or billing records or other records used to make decisions about you;
• is not available for inspection as set forth above; or
• is accurate and complete.

In any event, any agreed upon amendment will be included as an addition to, and not a replacement of, already existing records. In order to request an amendment to your PHI, you must submit your request in writing to Medical Record Custodian at our company, along with a description of the reason for your request. You have the right to receive an accounting of disclosures of PHI made by us to individuals or entities other than to you for the six years prior to your request, except for disclosures: to carry out treatment, payment and health care operations as provided above; incidental to a use or disclosure otherwise permitted or required by applicable law; pursuant to your written authorization

• Be treated with consideration, respect and full recognition of dignity and individuality, including privacy in treatment and care of personal needs without discrimination.
• Speak to a health professional.
• Receive information about the patient management program.
• Be fully informed of the patient management program, current care and any changes made, including termination, regarding the care and treatment to be provided by Hometown Specialty Pharmacy
• Know about philosophy and characteristics of the patient management program.
• Receive care appropriate to his/her needs and speak to a health care professional in a timely
• Receive prompt response to all reasonable inquiries or grievances.
• Identify the program's staff members, including their job title, and to speak with a staff member's Supervisor, if requested. staywellathometown.com/specialty - 3200 New Columbia Rd. Campbellsville KY, 42718 - 270-937-9008
• Be advised, before care is initiated, of the extent to which payment for the organization's services may be expected from Medicare / Medicaid, insurance, or the client's liability for payment, billing cycles, changes in payment.
• Be informed of any financial benefits when referred to an organization.
• Be informed of any provider limitations affecting treatment of care.
• Receive prompt response to all reasonable interruption of services.
• Be informed of any rights and responsibilities he/she may have in the care process.
• Receive the information necessary to make decisions regarding his/her care.
• Accept or refuse any treatment, or services, and revoke consent or disenroll at any point in time.

• A referral if the patient is denied services solely on his or her inability to pay.
• Have personal health information shared with the patient management program only in accordance with state and federal law.
• Voice grievance and recommend a change in policy, service or staff without fear, reprisal, discrimination or unreasonable interruption of service with the pharmacy at 270-937-9008.
• Appeal decisions made by Hometown Specialty Pharmacy concerning your healthcare. These appeals should be made in writing addressed to the Pharmacist in Charge.

All Patients have a Responsibility to:

• Give accurate and complete contact information, health information, disclose all medications and other pertinent items, and to notify Hometown Specialty Pharmacy of any changes in this information.
• Assist in developing and maintaining a safe environment for patient care.
• Participate in the development and update of their therapy care plan and adhere to the care plan.
• Request further information concerning anything they do not understand.
• Give information regarding concerns and problems they have to a Hometown Healthcare Specialty Pharmacy & Ambulatory Clinic staff member.
• Submit any forms that are necessary to participate in the program, to the extent required by law Inform Hometown Specialty Pharmacy if they are in the hospital, have utilized emergency services, and disclose all medications taken or changed.
• Notify their treating provider of their participation with Hometown Specialty Pharmacy Patient Enrolling in Hometown Specialty Pharmacy Patient Care Program has been provided documentation outlining their individual patient rights, financial obligation, consent to treat, and HIPPA privacy policy and understands that by signing agreeing to the terms of this established entity as described:

Patient or Guardian Signature Date:

Hometown Healthcare Representative Date: