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HIPPA/Privacy

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED OR DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. DIABETES CARE CLUB, INC. NOTICE OF USES, PROTECTED HEALTH INFORMATION, Effective March 1, 2002

In accordance with the requirements of the Health Insurance Portability and Accountability Act of 1996 ("HIPAA"), DIABETES CARE CLUB, Inc. ("DIABETES CARE CLUB") is required to inform you of its practices in relation to the protected health information that it maintains about you. HIPAA mandates minimum standards that a covered entity such as DIABETES CARE CLUB must maintain in relation to your protected health information. This Notice of Uses is being provided to help you understand how DIABETES CARE CLUB meets these minimum standards. It is also meant to inform you of the ways that DIABETES CARE CLUB may use the personal information it collects about you and how it may disclose it.

UNDERSTANDING YOUR PROTECTED HEALTH INFORMATION

When you receive care from a healthcare provider, a record of that treatment is made. This record will typically contain information on your diagnosis, treatment, and future plan of treatment and is often collectively referred to as your medical record. This medical record includes protected health information and lays the foundation for determining your plan of care and treatment and allows for a successful means of communication between all healthcare professionals that contribute to your care. HIPAA protects information found in your medical record from disclosure without your authorization. The information protected by HIPAA includes:

Any information related to your past, present or future physical or mental health; The past, present or future payment for health services you have received; The specific care that you have received, are receiving or will receive; Any information that identifies you as the individual receiving the care; and Any information that someone could reasonably use to identify you as receiving the care. This information is referred to as protected health information throughout this Notice.

TREATMENT, PAYMENT AND HEALTHCARE OPERATIONS

As a Covered Entity, DIABETES CARE CLUB is required to inform you of how it may use your protected health information. In providing treatment to you, DIABETES CARE CLUB will use your protected health information for the purposes of treatment, payment and healthcare operations. Treatment - As it pertains to DIABETES CARE CLUB, treatment means providing to you drugs, medications and supplies and durable medical equipment as ordered by your physician. Treatment also includes coordination and consultation with your physician and other health care providers. As DIABETES CARE CLUB provides these services to you, information obtained during this process will be recorded in your medical record. DIABETES CARE CLUB will use this information, in coordination with your physician, to determine the best course of treatment for you. Payment - Payment purposes consist of activities required to obtain reimbursement from your insurance carrier for the services ordered by your physician and provided to you by DIABETES CARE CLUB. This includes, but is not limited to, eligibility determination, pre-certification, billing and collection activities, obtaining documentation required by your insurer, and when applicable, disclosure of limited information to consumer reporting agencies. Healthcare operations - Operations can include, but are not limited to, review of your protected health information by members of DIABETES CARE CLUB's professional healthcare staff to ensure compliance with all federal and state regulations. This information will then be utilized to continually improve the quality and effectiveness of the services provided to you by DIABETES CARE CLUB. Healthcare operations also include DIABETES CARE CLUB's business management and general administrative activities.

OTHER USES AND DISCLOSURES

In order to release information contained in your medical record for purposes other than treatment, payment or healthcare operations, DIABETES CARE CLUB must obtain a specific signed authorization from you. You may revoke such authorization at any time, except to the extent DIABETES CARE CLUB has taken action in reliance on the authorization. There are a limited number of other uses and disclosures of protected health information that do not require a specific authorization from you. DIABETES CARE CLUB may in the following circumstances disclose your protected health information. DIABETES CARE CLUB may disclose to a member of your family, other relative, or a close personal friend, or any other person identified by you, the protected health information directly relevant to such person's involvement with your care or payment related to your health care; may disclose protected health information to others as required by law; may disclose protected health information for certain public health activities and purposes; may disclose protected health information to a legally-authorized government authority, such as a social service or protective services agency, if we reasonably believe you are a victim of abuse, neglect or domestic violence; may disclose protected health information for law enforcement purposes and in response to court orders or subpoenas; may disclose protected health information to agencies authorized by law to conduct health oversight activities, including audits, investigations, licensing and similar activities; may disclose protected health information to attorneys, accountants, and others acting on behalf of DIABETES CARE CLUB, provided they have signed written contracts agreeing to safeguard the confidentiality of the information.

YOUR RIGHTS AS A PATIENT OF DIABETES CARE CLUB

In accordance with HIPAA you have the following rights in relation to your protected health information: You may request, in writing, additional restrictions to the use or disclosure of your protected health information; however, DIABETES CARE CLUB is not required to agree to the requested restrictions. You have the right to request amendments to your medical record. You have the right to obtain a copy of this Notice of Uses. You have the right of access to inspect and obtain a copy of your medical record, subject to certain limitations. You have the right to obtain an accounting of disclosures of your medical record for purposes other than treatment, payment and healthcare operations. You have the right to request communications of your medical record by alternative means (i.e. electronically) or at alternative locations. You have the right to revoke authorization to use or disclose your protected health information except to the extent that action has already occurred.

RESPONSIBILITIES OF DIABETES CARE CLUB

In accordance with HIPAA, DIABETES CARE CLUB is required to: Maintain the confidentiality of your protected health information. Your state laws may provide more protection than the federal laws and, in that case, we will abide by the more restrictive statute. Provide you with notice of our legal obligations and privacy practices regarding information it may accumulate about you and is obligated to abide by the terms of this notice. Notify you if it is unable to agree to a requested restriction, and make every effort to accommodate reasonable requests for communication of health information by alternative means. Post its Notice of Uses on its website at www.diabetescareclub.com. Please be advised that in addition to these responsibilities, DIABETES CARE CLUB reserves the right to change the terms of its Notice of Uses and make those changes applicable to all protected health information maintained at that time. If there is a change to its Notice of Uses, may obtain a copy of the revised Notice of Uses by contacting the Privacy Officer at the address below. DIABETES CARE CLUB will not use or disclose your protected health information without your authorization, except as described in this notice.

FOR MORE INFORMATION OR TO REPORT A PROBLEM

If you have questions, would like additional information or, if you suspect misuse of your protected health information and believe that your rights have been violated, you may, without fear of retaliation, contact:Diabetes Care Club, LLC 961 Woodland Street, Suite 100 Nashville, TN 37206 or The Office of Civil Rights.U.S. Department of Health & Human Services Independence Avenue SW Room 509F HHH Building Washington D.C. 20201,1(800) 368-1019

PRIVACY: NOTICE OF USES-PURPOSE

To ensure compliance by DIABETES CARE CLUB with federal regulation created under the Health Insurance Portability and Accountability Act ("HIPAA") regarding the privacy of all protected health information ("PHI") maintained by DIABETES CARE CLUB. In particular, the purpose of this policy and procedure is to ensure compliance with HIPAA regulations related to Notice of Uses.

POLICY

DIABETES CARE CLUB must provide a Notice of Uses to each patient as required by HIPAA regulations. The Notice of Uses will explain to patients how DIABETES CARE CLUB may use and disclose the patient's PHI obtained by DIABETES CARE CLUB in the course of providing services to the patient.

PROCEDURE

The Notice of Uses must be provided to all patients who will be treated by DIABETES CARE CLUB with a date of service after April 14, 2003 prior to provision of service. After April 14, 2003, the Notice of Uses must be provided to all new patients at the time of initial delivery of services. The patient should sign an Acknowledgment verifying receipt of the Notice of Uses. DIABETES CARE CLUB shall provide an Acknowledgment to patients with the Notice of Uses. DIABETES CARE CLUB will make a good faith effort to see that the Acknowledgment is returned. If DIABETES CARE CLUB does not receive a signed Acknowledgment within thirty (30) days of providing the Notice of Uses, it shall call and inform the patient that it is forwarding an additional Notice of Uses and Acknowledgment and explain the importance of returning the Acknowledgment. These efforts shall be repeated at sixty (60) days and ninety (90) days if the Acknowledgment is not returned. At the end of one hundred twenty (120) days, the Privacy Officer shall review the documentation of the efforts to obtain a signed Acknowledgment and, if applicable, will determine a good faith effort has been made. If the documentation does not show a good faith effort, the Privacy Officer will direct additional efforts to be made. If a patient refuses to sign an acknowledgment, such action should be documented in the patient's medical record and the Privacy Officer notified. DIABETES CARE CLUB reserves the right to change the terms of the Notice of Uses and make those changes applicable to all PHI maintained at that time. If there is a change to the Notice of Uses, a revised Notice may be obtained by the patient upon the patient's request. DIABETES CARE CLUB shall at all times post a copy of its Notice of Uses on its website. DIABETES CARE CLUB shall post its Notice of Uses in a conspicuous location at its place of business.

The Medicare 21 Supplier Standards

  1. A supplier must be in compliance with all applicable Federal and State licensure and regulatory requirements.
  2. A supplier must provide complete and accurate information on the DMEPOS supplier application. Any changes to this information must be reported to the National Supplier Clearinghouse within 30 days.
  3. An authorized individual (one whose signature is binding) must sign the application for billing privileges.
  4. A supplier must fill orders from its own inventory, or must contract with other companies for the purchase of items necessary to fill the order. A supplier may not contract with any entity that is currently excluded from the Medicare program, any State health care programs, or from any other Federal procurement or non-procurement programs.
  5. A supplier must advise beneficiaries that they may rent or purchase inexpensive or routinely purchased durable medical equipment, and of the purchase option for capped rental equipment.
  6. A supplier must notify beneficiaries of warranty coverage and honor all warranties under applicable State law, and repair or replace free of charge Medicare covered items that are under warranty.
  7. A supplier must maintain a physical facility on an appropriate site.
  8. A supplier must permit CMS (formerly HCFA), or its agents to conduct on-site inspections to ascertain the supplier's compliance with these standards. The supplier location must be accessible to beneficiaries during reasonable business hours, and must maintain a visible sign and posted hours of operation.
  9. A supplier must maintain a primary business telephone listed under the name of the business in a local directory or a toll free number available through directory assistance. The exclusive use of a beeper, answering machine or cell phone is prohibited.
  10. A supplier must have comprehensive liability insurance in the amount of at least $300,000 that covers both the supplier's place of business and all customers and employees of the supplier. If the supplier manufactures its own items, this insurance must also cover product liability and completed operations.
  11. A supplier must agree not to initiate telephone contact with beneficiaries, with a few exceptions allowed. This standard prohibits suppliers from calling beneficiaries in order to solicit new business.
  12. A supplier is responsible for delivery and must instruct beneficiaries on use of Medicare covered items, and maintain proof of delivery.
  13. A supplier must answer questions and respond to complaints of beneficiaries, and maintain documentation of such contacts.
  14. A supplier must maintain and replace at no charge or repair directly, or through a service contract with another company, Medicare-covered items it has rented to beneficiaries.
  15. A supplier must accept returns of substandard (less than full quality for the particular item) or unsuitable items (inappropriate for the beneficiary at the time it was fitted and rented or sold) from beneficiaries.
  16. A supplier must disclose these supplier standards to each beneficiary to whom it supplies a Medicare-covered item.
  17. A supplier must disclose to the government any person having ownership, financial, or control interest in the supplier.
  18. A supplier must not convey or reassign a supplier number; i.e., the supplier may not sell or allow another entity to use its Medicare billing number.
  19. A supplier must have a complaint resolution protocol established to address beneficiary complaints that relate to these standards. A record of these complaints must be maintained at the physical facility.
  20. Complaint records must include: the name, address, telephone number and health insurance claim number of the beneficiary, a summary of the complaint, and any actions taken to resolve it.
  21. A supplier must agree to furnish CMS (formerly HCFA) any information required by the Medicare statute and implementing regulations.

I authorize Diabetes Care Club to file my insurance benefits and I would like my insurer to pay the Club for the products that they send me. I authorize Diabetes Care Club to collect the necessary information to be able to file my claim, and to contact me, as needed about things related to my supplies. I acknowledge that I have received a copy of Diabetes Care Club, LLC's Notice of Privacy Practices, all HIPAA required documentation and the Medicare 21 Standards. This Notice describes how Diabetes Care Club, LLC may use and disclose my protected health information, and rights I may have regarding my protected health information. I also authorize for disclosure to Diabetes Care Club, LLC at 961 Woodland Street, Nashville, TN 37206 of my health information relating to Medical History, Examination reports, Treatment or Tests, Prescriptions and all Diabetes related health information. This authorization will remain in effect until January 1, 2020. I authorize Diabetes Care Club to file my insurance benefits and I would like my insurer to pay the Club for the products that they send me. I authorize Diabetes Care Club to collect the necessary information to be able to file my claim, and to contact me, as needed about things related to my supplies.

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