Notice of Privacy Practices (HIPAA)

Effective Date: September 20, 2025
Last Updated: September 20, 2025

This Notice describes how medical information about you may be used and disclosed, and how you can access this information. Please review it carefully.

Our Responsibilities

  • Maintain the privacy of your health information.

  • Provide you with this Notice of our legal duties and privacy practices.

  • Follow the terms of this Notice.

  • Notify you if a breach occurs that may have compromised the privacy or security of your information.

How We May Use and Disclose Your Health Information

  • Treatment: To provide care, coordinate services, and send prescriptions to pharmacies (such as Olympia Pharmacy) or labs.

  • Payment: To bill and collect payment for services.

  • Healthcare Operations: For quality improvement, training, auditing, and compliance.

  • Legal Requirements: To comply with federal, state, or local laws.

  • Public Health & Safety: To prevent disease, report adverse events, or protect from serious health threats.

  • Law Enforcement: If required by law, court order, or subpoena.

  • Other Uses: Only with your written authorization. You may revoke an authorization at any time.

Your Rights

  • Access: Request a copy of your medical records, electronic or paper.

  • Corrections: Ask us to correct inaccurate or incomplete information.

  • Restrictions: Request limits on use or disclosure of your information.

  • Confidential Communications: Request alternative contact methods (e.g., email instead of phone).

  • Accounting of Disclosures: Request a list of times we shared your information.

  • Copy of This Notice: Request a printed or electronic copy at any time.

  • File a Complaint: You may file a complaint with us or with the U.S. Department of Health and Human Services (HHS). Filing a complaint will not affect your care.

Partner Pharmacy Contact Information

Olympia Pharmacy
6700 Conroy Rd. Orlando, FL 32835
Phone: 407-673-2222
Fax: 407-704-3651
Website: www.olympiapharmacy.com

Contact Us

FormKind Health – Privacy Officer
Email: [Insert HIPAA Privacy Email]
Website: [Insert Website URL]

You may also contact:
U.S. Department of Health & Human Services (HHS)
Office for Civil Rights
Phone: 1-800-368-1019
Website: https://www.hhs.gov/ocr/privacy/hipaa/complaints/

Changes to This Notice

We may change our privacy practices at any time. Changes will apply to all medical information we maintain and will be posted on our website with the updated effective date.