ICP will obtain from the patient, written authorization for any use or disclosure of PHI not described in this notice. Written authorization will be made by completing a "Patient Written Authorization Form" provided by ICP, and by proving at least one form of picture identification, i.e. driver's licenses . The patient may revoke any written authorization at any time, with the submission of a request in writing.
All authorizations and revocations will become part of the patient's record.
ICP may contact the patient in order to provide refill reminders, information on treatment alternatives, or other health-related benefits or services. To provide written approval to receive information from ICP in the form of e-mail, fax, or newsletter, please sign the "Receive Information" box below. ICP will not use or provide patient PHI to be used in any marketing or promotional programs.
Patient's Rights include:
ICP's legal duties include:
The patient may register a complaint with the secretary of the U.S. Department of Health and Human Services or with ICP directly, if his or her privacy rights are violated by the pharmacy. See ICP contact information below. It is important to remember that it is your right to file a complaint and that the patient will not face retaliation for filing a complaint.
ICP's Privacy Officer is Gordon E. Mote, Ph.D., M.B.A. Please feel free to contact him, at (909) 478-3842 by phone, or 24747 Redlands Blvd., Suite F., Loma Linda, CA 92354, by mail, regarding further information about the pharmacy's privacy policies or to register a complaint.
The Effective date of the Notice of Privacy Practices is April 14, 2003.