To speak with a pharmacist about your medication, please call 1-540-477-3101.
Patient Information Sheet
Please call your prescriber for medical advice about side effects. You may report side effects to the FDA at 1-800-FDA-1088.
This medicine was compounded specifically for you in our pharmacy to fill the prescription your prescriber wrote for you. It was specially made to meet your individual needs. As a result, no standard information or literature is available for this prescription. If you have not done so, please discuss this medicine with your prescriber or pharmacist to ensure that you understand why you have been prescribed a compounded medication and the interactions, if any, this medicine may have with other medications you are taking. Compounding is a long standing pharmaceutical practice that allows prescribers to treat their patient’s individual needs without being restricted to “off-the-shelf” medicines or devices. This medicine was compounded in our pharmacy to meet the specifications ordered by your prescriber.
Call your prescriber or pharmacist if:
- You experience any side effects.
- You are taking additional medicines that may interact with this compounded medicine.
- You have allergies or other medical conditions that should be noted.
Call our pharmacist if:
- The information on the label is not clear to you.
This medicine will be used by your prescriber to perform patch testing. Because this is a topical medication, systemic effects are not expected. The most common reaction experienced with this medicine is redness, irritation, and pruritus at the site of application. Nonetheless, you should report any discomfort that you may experience after the application of this medicine either to your prescriber or pharmacist.
Our pharmacist is available to address any additional questions or concerns that you may have.
NOTICE OF PRIVACY PRACTICES 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.
SECTION A: Uses and Disclosures of Protected Health Information
Under applicable law, we are required to protect the privacy of your individual health information (information we refer to in this notice as “Protected Health Information”). We are also required to provide you with this notice regarding our policies and procedures regarding your Protected Health Information (referred to as “PHI”) and to abide by the terms of this notice. It may be updated from time to time.
We are permitted to make certain types of uses and disclosures under applicable law for treatment, payment, and healthcare operations purposes. For treatment purposes, such uses and disclosures will take place in providing, coordinating, or managing healthcare and its related services by one or more of your providers, such as when your pharmacist consults with your practitioner regarding your medications, treatment or condition.
For payment purposes, such use and disclosure will take place to obtain or provide reimbursement for providing pharmaceutical care services, such as when your case is reviewed to ensure appropriate care was rendered. For reimbursement purposes, your PHI may be disclosed to one or several intermediaries employed by your plan sponsor including but not limited to insurers, pharmacy benefits managers, claims administrators and computer switching companies.
For healthcare operations purposes, such use and disclosure will take place in several ways, including for quality assessment and improvement, provider review and training, underwriting activities, reviews and compliance activities, planning, development, management and administration. Your information could be used, for example, to assist in the evaluation of the quality of care you were provided.
In addition, we may contact you to provide refill reminders, other follow up, information about treatment options or other health-related benefits and services. In addition, we may disclose your health information to your plan sponsor.
We may use and disclose your PHI if we are contacted by another pharmacy who states they have your request and consent to transfer pharmacy records to them.
From time to time, we may employ the services of business associates who may assist us in one or more tasks and who may use, change or create PHI. Business associates are required to comply with all privacy regulations on your behalf.
We may disclose PHI about you without your authorization to comply with workers compensation laws, as required by law enforcement, legal proceedings, and public health requirements, health oversight activities and as required by law.
Other uses and disclosures will be made only with your written authorization, and you may revoke your authorization at any time by notifying us as described in Section B.
You may ask us to restrict uses and disclosures of your PHI to carry out treatment, payment, or healthcare operations, or to restrict uses and disclosures to family members, relatives, friends or other persons identified by you who are involved in your care or payment for your care. However, we are not required to agree to your request.
You have the right to request the following with respect to your PHI: (i) inspection and copying; (ii) amendment or correction; (iii) an accounting of the disclosures of this information by us; (We are not required to account to you for disclosures made for treatment, payment, operations, disclosures to you, disclosures to your care givers, for notifications or as otherwise excluded by law), and (iv) receipt of a paper copy of this notice upon request. Requests for access to PHI must be made in writing.
In addition, you may request, and we must accommodate the request, if reasonable, to receive communications of PHI by alternative means or at alternative locations. To make this request, please contact us as described in Section B.
The Pharmacy may charge for supplies, labor and the postage involved in preparing PHI for your request. If you desire a price quote for this service, you must request one. You have the right to withdraw your request of the PHI prior to the delivery.
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires that we provide you with this privacy notice. Additionally, we are required to ask you to sign an acknowledgement that you have received this notice.
We may use your name to reference your prescriptions and pharmaceutical care services. You may be required to sign a signature form to acknowledge receipt of this notice and the disclosure of PHI as outlined herein. You may restrict or prohibit these uses and disclosures by notifying a pharmacy representative orally or in writing of your restriction or prohibition. We are not required to honor those requests. If you request our services, we are able to provide treatment services to you, even if you object to signing the acknowledgment of the receipt of this notice or if we decide not to honor a request regarding the information in this document while noting your requests and refusals in our records. In the event of an emergency or your incapacity, we will do in our reasonable judgment what is consistent with your known preference, and what we determine to be in your best interest. We will inform you of any such issues or disclosures under such circumstances and give you an opportunity to object as soon as practicable.
We may disclose to one of your family members, to a relative, to a close personal friend, or to any other person identified by you, PHI that is directly relevant to the person’s involvement with your care or payment related to your care. In addition, unless you object, we may use or disclosure the PHI to notify, identify, or locate a member of your family, your personal representatives, another person responsible for care, or certain disaster relief agencies of your location, general condition, or death. If you are incapacitated, there is an emergency, or you object to the use or disclosure, we will do what in our judgment is in your best interest regarding such disclosure and will disclose only the information that is directly relevant to the person’s involvement with your care. We will also use our judgment and experience regarding your best interest in allowing people to pick up filled prescriptions, or similar forms of PHI.
We reserve the right to change the terms of this notice and to make new notice provisions effective for all PHI we maintain. You may receive a copy of this notice by contacting us as outlined in Section B or upon receipt of pharmacy care services.
We are required by law to maintain the privacy of your protected health information, to provide you with notice of our legal duties and privacy practices with respect to protected health information, and to notify you following a breach of unsecured protected health information.
If you believe that your privacy rights have been violated, you may file a complaint with us at the location described in Section B or to the Secretary of the Department of Health and Human Services, Hubert H. Humphrey Building, 200 Independence Ave. SW, Washington, DC 20201. You will not be retaliated against for filing a complaint.
SECTION B: Contacting Us
This notice was published and becomes effective on/or before August 4, 2023.
We are required by law to maintain the privacy of, and provide individuals with, this notice of our legal duties and privacy practices with respect to protected health information. If you have any questions about this form, please ask to speak with our Privacy Officer,
5350 Main St Mount Jackson, Virginia 22842Telephone 540-477-3101 fax 540-477-4039
Signature below is only acknowledgement that you have received this Notice of our Privacy Practices.
Patient’s Name:
Date:
Model Notices of Privacy Practices
If you have any questions or concerns regarding our HIPAA policies and procedures, feel free to contact us today.
