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Rx Group ID: 99999999
Group Name: ABC Company
Cardholder ID: 234312312
Cardholder Name: JOHN TEST
Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), you have the right to view protected
health information (PHI) that pertains to you or a legal dependent. (PHI is "any information that identifies an individual
and relates to an individual's past, present or future physical or mental health condition, health care treatment, or
payment for health care services".) MedTrakRx maintains PHI in the form of prescription claims histories.
Under HIPAA privacy regulations:
You are about to view prescription claims information across a secure site. You, the recipient, are obligated to
maintain this information in a safe, secure and confidential manner. Unauthorized re-disclosure or failure to maintain
confidentiality could subject you to penalties described in federal or state law.
Please type your initials below to indicate that you've read and understand this statement.
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