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.

The Health Insurance Portability and Accountability Act (HIPAA) was passed to promote standardization and efficiency within the healthcare industry. It also establishes certain privacy and security requirements that apply to Protected Health Information (PHI), which includes any information held by healthcare providers that relates to your past, present, or future medical conditions, the provision of health care to you, or the past, present or future payment for the provision of health care, and which may specifically identify you.  We at Avella Specialty Pharmacy, Inc. (Avella) would like to make you aware of your rights and our responsibilities with regard to your PHI, as identified by HIPAA.

HIPAA Authorization form: Complete and return this form to give your permission to discuss and/or release your personal health information (PHI) to a person who is your Authorized Representative.

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.  A paper copy of this Notice can be obtained from the receptionist at any of our sites and is also available as a PDF download HERE.

You have the right to uses or disclosures of your information for treatment, payment, or health care operations. You also have the right to ask to restrict disclosures to family members or to others who are involved in your health care or payment for your health care. You must make a written request to restrict the use or disclosure of your information. Please note that while we will try to honor your request, we are not required to agree to any restriction other than with respect to certain disclosures to health plans as further described in this notice. Please see the section called “Making a Written Request” for instructions.

You have the right to ask to receive confidential communications by asking us to send information by alternative means or at alternative locations — for example, to another address instead of your home address. You must make a written request to receive confidential communications or to cancel or change an earlier request. We will honor reasonable requests. Please see the section called “Making a Written Request” for instructions.

You have the right to see and obtain a copy of certain of your health information maintained by us, such as your medical records and billing records. If we maintain a copy of your health information electronically, you will have the right to request that we send a copy of your health information in an electronic format to you. You can also request that we provide a copy of your information to a third party that you name. In some cases, you also may receive a summary of this health information. You must make a written request to inspect and obtain a copy of your health information. In certain cases, we may deny your request to inspect and copy your health information. If we deny your request, you may have the right to have the denial reviewed. We may charge a reasonable fee for any copies.

Access to Protected Health Information: Use THIS FORM to request copies of your records

You have the right to receive a listing of certain disclosures of your information made by us during the six years before your request. This list will not include disclosures of information made: (i) for treatment, payment, and health care operations purposes; (ii) to you or people you authorized; (iii) to correctional institutions or law enforcement officials; and (iv) other disclosures for which federal law does not require us to keep track of. You must submit a written request for a list of disclosures. Please see the “Making a Written Request” section for instructions.

You have a right to ask to make changes to certain health information we maintain about you, such as medical records and billing records, if you believe the health information about you is wrong or incomplete. You must make a written request to change your information and explain your reason(s) for the requested change(s). If we deny your request, you may have a statement of your disagreement added to your health information. Please see the “Making a Written Request” section for instructions.

All requests or communications to us to exercise your rights described above must be submitted in writing to:

Optum Specialty Pharmacy
Attention: Privacy Officer
24416 N 19th Avenue
Phoenix, Arizona 85085

We may process some or all your prescription(s) at any of our Optum Specialty Pharmacy locations.  If you have questions, please call the phone number on your prescription label.

Questions about this notice or to file a complaint. If you have questions about this notice, please contact us as outlined below. Also, if you believe your privacy rights have been violated, you may file a complaint with us. You may also notify the Secretary of the U.S. Department of Health and Human Services of your complaint. We will not take any action against you for filing a complaint.

Contact us by mail:
Optum Specialty Pharmacy
Attention: Privacy Officer
24416 N 19th Avenue
Phoenix, Arizona 85085