Privacy Office                                                                                    1-866-329-7592

PO Box 38115

Pittsburgh, PA 15238

PharmaCare Direct

Privacy Complaint Form

As required by the Health Insurance Portability and Accountability Act of 1996 you have a right to complain about PharmaCare Directs privacy policies, procedures or actions.

Please fill out this form completely and accurately. Within 30 days of receipt of this Complaint Form, the Privacy Office will review and respond to your Complaint. If you need assistance completing this form, please call 1-866-329-7592 and a Privacy Office Representative will assist you.

Please note the Pharmacy cannot accept this form. It is your responsibility to mail this form to the Privacy Office at the address listed above.

Please complete the sections below. (You are not required to provide your name and contact information, but we will be unable to respond to your complaint if you choose not to provide this information on this Complaint Form.)

Name: ________________________________________

Address: ______________________________________

Phone: ________________________________________

Member Number: _______________________________

Best way to reach you? ___________________________

Best time to reach you? ___________________________

This complaint relates to:

____ PharmaCare Direct Pittsburgh Mail Service Facility

____ PharmaCare Direct Clearwater (Largo) Mail Service Facility

____ Other (explain) __________________________________________________________

Details of your complaint: (Please be as specific as possible with dates, times and the specific policy, procedure, or action taken. Include the names of any mail service associate(s) with whom you discussed this matter, and identify pharmacy location. Use the other side of this form or attach a separate page if you need more room.)

Signature _______________________________

Date ____________________________________