The Health Insurance Portability & Accountability Act of 1996 (“HIPAA”) is a Federal law that requires that all individually identifiable health information about you, called protected health information or “PHI,” used or disclosed by us in any form, whether electronically, on paper, or orally is kept properly confidential. This Act gives you, the patient, the right to understand and control how your protected health information is used. HIPAA provides penalties for health care providers that misuse protected health information.

As required by HIPAA, Advanced Dermatology and Skin Care, P.A. (hereinafter “we”) prepared this explanation of how we will maintain the privacy of your health information and how we may use and disclose your personal information.

This notice is effective as of September 22, 2015 and it is our intention to abide by the terms of the Notice of Privacy Practices and HIPAA Regulations currently in effect. We reserve the right to change the terms of our Notice of Privacy Practice and to make the new notice provision effective for all PHI that we maintain. We will post and you may request a written copy of the revised Notice of Privacy Practice from our office.

We may use and disclose your PHI without your authorization only for the following purposes:

  • We may use and disclose your PHI in order to provide you treatment. This includes providing, coordinating, or managing health care and related services for you. An example of this would include referring you to a retina specialist.
  • We may use and disclose your PHI as necessary to obtain payment for the health care services we provide to you. This includes such activities as obtaining reimbursement for services, confirming coverage, billing or collections activities, and utilization review. An example of this would include sending your insurance company a bill for your visit and/or verifying coverage prior to a surgery.
  • Health Care Operations. We may use and disclose your PHI to help run our business. This includes conducting quality assessments and improving activities, auditing functions, cost management analysis, and customer service. An example of this would be sending a new patient survey about a visit. We may also use or disclose your PHI if all or part of our business is sold, transferred, leased, or combined, or if your doctor dies or leaves the
  • Provide You With Treatment Alternatives. We may use or disclose your PHI to provide you information about alternative treatments or other health-related services that we provide that might be of interest to you.
  • Business Associates. We may share your PHI with third party vendors that perform various activities and services on our behalf, called “business associates.” Whenever we use a business associate to perform services for us that involve the use or disclosure of PHI, we will have a written agreement with that business associate that requires it to protect the privacy and confidentiality of your PHI.
  • Others Involved in Your Care. Unless you object, we may disclose your PHI to a family member, friend or other person that you identify as involved in your care when that information is relevant to their involvement, or necessary to inform them of your condition or location.
  • Health Oversight. Several state and federal laws and regulations may require us to disclose your medical information to federal or state agencies for health oversight activities such as audits, investigations, inspections, and licensure of our practice and of the providers who treat you. These activities are necessary for the government to monitor us to make sure we are doing what we are supposed to do under the law.
  • Public Health. We may disclose information about you to a public health authority or agency for public health activities, such as reporting communicable diseases.
  • As Required By Law. We may disclose your PHI when required to do so by federal, state or local law, or when necessary to comply with a valid court order, subpoena or other legal process related to a judicial or administrative proceeding.
  • Law Enforcement. We may disclose your health information to law enforcement officials in limited circumstances when permitted or required by law.
  • Abuse, Neglect, Crime Reporting, or Serious Threat. We may release health information about you as permitted or required by law when we believe you may be the victim of abuse or neglect, or to report a crime. We may also disclose your information when necessary to avoid a serious threat to the health or safety of you or others.
  • Government Functions. We may disclose your health information to authorized federal authorities as required for intelligence, counterintelligence or national security purposes. We may also disclose your health information as required by military authorities if you are a member of the armed forces.
  • Organ and Tissue Donation. If you are an organ donor, we may disclose your PHI to organizations that handle organ or tissue procurement or transplantation as necessary to facilitate organ or tissue donation or transplantation.
  • Coroners or Funeral Directors. We may disclose health information about a deceased individual to coroners or funeral directors.
  • Workers’ Compensation. We may disclose your health information to the extent authorized by and as necessary to comply with laws relating to workers’ compensation or other similar programs established by law.

The following use and disclosures of your PHI will only be made pursuant to us receiving a written authorization from you:

  • Most uses and disclosure of psychotherapy notes (although we would never generally have such information);
  • Uses and disclosure of your PHI for marketing purposes, including subsidized health care communications;
  • Disclosures that constitute a sale of PHI under HIPAA; and
  • Other uses and disclosures not described in this notice.

If you provide us with an authorization, you may revoke such authorization in writing at any time and we are required to honor and abide by that written request, except to the extent that we have already used or disclosed your information in reliance on your authorization. You may have the following rights with respect to your PHI. Requests to exercise any of these rights must be made in writing.

  • The right to request restrictions on certain uses and disclosures of PHI, including those related to disclosures to family members, other relatives, close personal friends, or any other person identified by you. We will consider all reasonable requests for restrictions, however we are not required to honor all requests. If we do agree to the restriction, we must abide by it unless you agree in writing to remove it.
  • If you have paid for services “out of pocket”, in full at the time of the service, and you request that we not disclose PHI related solely to those services to a health plan, we will accommodate your request, except where we are required by law to make a disclosure.
  • The right to request to receive communications from us using specific means or at a certain location. We will honor reasonable requests.
  • The right to inspect and copy your PHI, and may request an electronic copy if your information is maintained electronically. We may charge a reasonable fee to cover the cost of copying your health information. We may refuse your request in limited circumstances established by law.
  • The right to request that we amend your PHI. Requests for amendment must explain in writing why you believe the information in our records is incorrect. We are not required to agree to your request for amendment.
  • The right to receive an accounting of disclosures of your PHI during the six (6) years preceding your request. The accounting will not include disclosures made for treatment, payment, health care operations or as specifically authorized by you.
  • The right to obtain a paper copy of this notice from us upon request.
  • The right to be advised if the security of your unsecured PHI is breached.

We are required by law to maintain the privacy of your PHI and to provide you this notice of our legal duties and our privacy practice with respect to PHI.

You have recourse if you feel that your rights have been violated by our office. You have the right to file a formal, written complaint with our office or with the Department of Health and Human Services, Office of Civil Rights. We will not retaliate against you for filing a complaint.

Consent for Treatment

I hereby consent to all medical and surgical procedures, including but not limited to laboratory, biologic tests and administration of local anesthesia which are deemed appropriate and necessary at any time while under the care of the physicians at Advanced Dermatology and Skin Care, P.A.

Tissue samples may be needed to diagnose your condition. Both malignant and benign growths and conditions may require a surgical procedure called a biopsy.  A local anesthetic is used prior to taking this tissue sample. This simple procedure carries with it minor risks such as: allergic reactions to the anesthesia, fainting, mild discomfort, minimal bleeding, the possibility of minor scarring and infection. The risks of not having the procedure done should be discussed with the physician.

It is the policy of this office to send all surgically removed specimens for expert consultation regardless of the pre-biopsy diagnosis. You may be responsible for any charges not covered by your health insurance.

I have read the above statements and understand the risks associated with a tissue biopsy. I also agree to have a biopsy performed by the practitioner if clinically indicated and sent to a pathology laboratory for analysis. I am aware that any outside services not covered by my insurance are my responsibility. I also authorize: Advanced Dermatology and Skin Care, P.A. physicians to release any information regarding my examination or treatment to my insurance company for processing of claims and/or to my referring physician.

Credit Card Authorization

By signing below, I authorize Advanced Dermatology to collect my credit card data for payment.

This payment authorization is for the products and/or services provided to me by Advanced Dermatology. I certify that I am an authorized user of this credit card and that I will not dispute the payment with my credit card company for professional services after those services have been rendered.

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