RPhon the go RPh On The Go USA, Inc. 8001 N. Lincoln Ave. Suite 800 Skokie, IL 60077

www.rphonthego.com Tel: 847.588.7170 1.800.553.7359 Fax: 847.588.7060

Dear Independent Contractor: Welcome to new opportunities in pharmacy placement. As an independent contractor, you are a vendor to RPh on the Go and our parent company, Adecco North America. Enclosed are the following forms for you to complete and return to us: ̌ Independent Contractor Agreement — Please read and sign where indicated. ̌ Application and Skills Checklist — Fill out completely, sign and date. ̌ Request for References — Recent, pharmacy-related references are required. ̌ HIPAA Review Acknowledgement — Please review the material and initial the

acknowledgement. ̌ W-9 Form — Follow the instructions to complete, sign and date. ̌ Background Check Authorization Forms — Please complete these forms completely,

sign and date. Along with these forms, please include copies of the following: ̌ Resume ̌ Pharmacist License(s) ̌ TB Test Results or chest x-ray results from the last year, if you will be working in a

hospital ̌ Certificate of Liability Insurance Also included in this packet is some general company information and policies. Please note that we require an FEIN number from each independent contractor. As an independent contractor, you are required to submit an invoice on your letterhead, as well as our standard timecard signed by the client, for each project you complete for RPh on the Go. Finally, some of our clients may require additional materials from you, such as a recent MMR, proof of varicella immunization, proprietary training on their systems and processes, a physical exam or other requirements. We will contact you as these items are needed. Thank you for your interest in joining our diverse and dynamic healthcare team. Please call 800-553-7359 with any questions. My best,

Steve Steve Sidell Director, Quality Assurance & Compliance enc.

RPH on the Go, HIPAA Verification page 1

Please read these training materials, sign and FAX theverification form to (847)982-7401 or mail to

RPh on the Go, 8001 Lincoln Avenue, Suite 800, Skokie, IL 60077.

RPh on the Go Contractors and HIPAA

IntroductionAll registered pharmacists are legally liable for understanding the requirements of Title II of the Health Insurance Portability and Accounting Act (HIPAA). Because you work with RPh on the Go, we have prepared the following materials to provide a training review of the administrative burdens related to handling a patient’s personal health information.

Our clients distribute Privacy Notices to their patients with each prescription and have established procedures for counseling patients and handling patient information. It is your responsibility to review the HIPAA policies with each client to ensure you are following their most recent procedures.

What is the purpose of HIPAA?

! To provide health insurance portability from one employer to another ! To improve healthcare efficiency by standardizing the exchange of medical information ! To protect the patient’s privacy against the misuse or improper disclosure of health records

Who is affected by HIPAA? All contractors who may have access to a patient’s health information, including: employee pharmacists, relief pharmacists, owner pharmacists, consultant pharmacists, health care system pharmacists, interns, health care providers, health plan administrators, pharmacy technicians and support staff.

What is the definition of Personal Health Information (PHI)? PHI is any “individually identifiable” health information transmitted through conversation, computer or paper. This includes conversations with a patient, physician, nurse, clinic, health insurance representative or pharmacy technician. Identifiable information includes a patient’s name, address, social securit6y number, email address, photograph, date of birth, gender, fax or phone number, driver’s license or relative’s name.

HIPAA does allow for the use or disclosure of PHI to provide treatment, to collect payment or to conduct health care operations.Treatment is defined as dispensing, DUR counseling, disease management and refill reminders. Collecting payment is defined as verifying insurance coverage, reconciliation of claims and third-party billing. Operations are defined as malpractice insurance and information management, including hardware, software and database management.

In addition, you may disclose PHI when required by law enforcement investigations, court orders, subpoenas, government benefit programs, State Boards of Pharmacy, the FDA for adverse events or product defects/recalls or the Department of Health of CDC for disease or injury reporting.

RPH on the Go, HIPAA Verification page 2

How does HIPAA affect pharmacy operations? When you counsel a patient regarding their medication, either in person or on the phone, you should keep your voice low and attempt to do so in a discrete area, so others cannot eavesdrop. PHI should not be within open view of other patients, guests, customers, pharmaceutical sales reps or delivery personnel.

At the start of any assignment, it is imperative that you review each client’s operations policies regarding documents and prescription vials containing PHI. Most pharmacies staple the prescription receipt on the outside of the bag for identification purposes. To protect the patient’s privacy, the pharmacy may use a smaller type font so this information is not visible. At the register checkout, the pharmacy may place the receipt inside the bag or fold the receipt inside out and staple it to the outside of the bag.

To discard paper documents containing PHI, either tear or shred the document. Either return the old vial to the customer or destroy the label before tossing any vial.

What is the Notice of Privacy Practices (NOPP)? Effective with any prescriptions filled after April 13, 2003, HIPAA requires that you post a copy of the Notice of Privacy Practices in the pharmacy and provide a copy to each patient. This notice describes the patient’s privacy rights and how the pharmacy intends to use and disclose PHI.

You must attempt to obtain the patient’s written acknowledgement that he/she has received the pharmacy’s privacy policy. Follow the client’s procedure.

If the patient refuses to sign, you are required to document your efforts to obtain a signature and the reason why the patient did not comply. A parent or guardian may sign for a child’s prescription. Again, follow the client’s procedure.

If requested by the patient, you are required to provide a written account of disclosures of PHI and the pharmacy’s prescription records for up to six years prior to the date of request, but not prior to HIPAA’s effective date of April 13, 2003. Patients may request additional restrictions on the use or disclosure of their PHI and the type of communications they prefer. Please follow the client’s procedure in these situations.

Complaint Procedures If a patient feels the pharmacy has breached their privacy by inappropriately sharing their PHI, communicate that the pharmacy makes every attempt to respect their right to privacy. If the patient decides to pursue this further, provide the contact information as described in the NOPP. In addition, a formal complaint may be filed with the Secretary of Health and Human Services, as listed on the NOPP. It is imperative that you also contact RPH on the Go, at 800-553-7359, with any formal complaints filed by a patient.

How does HIPAA affect state laws? HIPAA is a federal law that supercedes less stringent state laws, but not more stringent state laws.

What are the legal consequences of non-compliance with HIPAA? The following sanctions apply to individuals, as well as employers:

! Civil penalties up to $25,000 per rule violation ! Criminal penalties up to $50,000 and one year in prison for knowingly and improperly obtaining

or disclosing PHI ! Up to a $250,000 fine and 10 years in prison for the sale, use or transfer of private health

information for personal gain or malicious harm

RPH on the Go, HIPAA Verification page 3

RPh on the Go Contractors and HIPAA

Health Insurance Portability and Accountability Act (HIPAA) Title II Requirements

Verification Form

I have reviewed the training materials regarding the implementation and legal consequences of HIPAA, Title II. I understand that I am responsible for reviewing each client’s procedures on protecting the patient’s private health information.

Contractor Name (print): ________________________________________________________

Contractor Signature:___________________________________________________________

Date: _______________________________________________________________________

Please return this signed verification form before your next assignment. Please FAX to (847)982-7401 or mail to: RPh on the Go USA, Inc., 8001 Lincoln Avenue, Suite 800, Skokie, IL 60077.

All Specialty Companies/FCRA Acknowledgement & Consent Rev. 11/2010

ACKNOWLEDGEMENT AND CONSENT FOR RELEASE OF CONSUMER REPORTS

In connection with your application for employment with the Company (including contract for services), understand that consumer reports or investigative consumer reports which may contain public record information may be requested or made on you including consumer credit, criminal records, driving record, education, prior employer verification, workers compensation claims and others. These reports will include experience information along with reasons for termination of past employment. Further, understand that information from various Federal, State, local and other agencies which contain your past activities will be requested. A consumer report containing injury and illness records and medical information may be obtained only after a tentative offer of employment has been made.

You have the right to make a request of First Advantage Corporation, 100 Carillon Parkway, St. Petersburg, FL 33716, (727) 214-3411, upon proper identification and the payment of any authorized fees, for the information in its files on you at the time of your request.

You hereby authorize and request, without any reservation, any present or former employer, school, police department, financial institution, division of motor vehicles, consumer reporting agencies, or other persons or agencies having knowledge about you to furnish First Advantage Corporation with any and all background information in their possession regarding you, in order that your employment qualifications may be evaluated.

By signing below, you hereby authorize without reservation, any party or agency contacted by this employer to furnish the above-mentioned information. You further authorize ongoing procurement of the above-mentioned reports at any time during your employment (or contract). You also agree that a fax or photocopy of this authorization with your signature be accepted with the same authority as the original. Finally, you understand that the reporting of negative or adverse information will not necessarily disqualify you from employment, assignment, placement or advancement.

THIS ACKNOWLEDGES THAT I UNDERSTAND AND CONSENT TO THE REPORTING OF CONSUMER REPORT AND CONSUMER INVESTIGATIVE REPORT INFORMATION ON ME NOW AND IN THE FUTURE.

__________________________________ __________________________________ ________________________ Signed Full Name Printed Full Name Date

For all Consultants, Hourly Associates and Direct Hire Candidates I also consent to the sharing and transferring of information reported or learned about me to the Company’s clients, affiliates and subsidiaries, now and at the time that I seek or maintain employment, assignment, or placement with or through any of them.

__________________________________ __________________________________ ________________________ Signed Full Name Printed Full Name Date

For California, Minnesota or Oklahoma applicants only, if you would like to receive a copy of the consumer report, if one is obtained, please check this box

NOTICE TO CALIFORNIA APPLICANTS

Under section 1786.22 of the California Civil Code, you may view the file maintained on you by the consumer reporting agency named above during normal business hours. You may also obtain a copy of this file upon submitting proper identification and paying the costs of duplication services, by appearing at the Consumer Reporting Agency identified above in person or by mail. You may also receive a summary of the file by telephone. The agency is required to have personnel available to explain your file to you and the agency must explain to you any coded information appearing in your file. If you appear in person, a person of your choice may accompany you, provided that this person furnishes proper identification.