OUR PLEDGE REGARDING HEALTH INFORMATION:

We understand that health information about you and your health care is personal.  We are committed to protecting health information about you.  We create a record of the care and services you receive from us.  We need this record to provide you with quality care and to comply with certain legal requirements.  This notice applies to all of the records of your care generated by this health care practice, whether made by your personal doctor or others working in this office.  This notice will tell you about the ways in which we may use and disclose health information about you.  We also describe your rights to the health information we keep about you, and describe certain obligations we have regarding the use and disclosure of your health information.

We are required by law to:

• make sure that health information that identifies you is kept private;
• give you this notice of our legal duties and privacy practices with respect to health information about you; and
• follow the terms of the notice that is currently ineffect.

HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU.

The following categories describe different ways that we use and disclose health information.  For each category of uses or disclosures we will explain what we mean and try to give some examples.  The examples of uses and disclosures are not exclusive.

For Treatment:  We may use health information about you for a medical emergency when the doctor is unable to obtain your consent due to your condition or the nature of the medical emergency.  We may disclose health information about you to doctors, nurses, technicians, health students, or other personnel who are involved in taking care of you.  They may work at our offices, at the hospital (if you are hospitalized under our supervision), or at another doctor’s office, lab, pharmacy, or health care provider to whom we may refer you for consultation, to take x-rays, to perform lab tests, to have prescriptions filled, or for other treatment purposes.  For example, a doctor treating you for a broken leg may need to know if you have diabetes because diabetes may slow the healing process.  In addition, the doctor may need to tell the dietitian at the hospital if you have diabetes so that we can arrange for appropriate meals.

For Payment:  With your consent, we may use and disclose health information about you so that the treatment and services you receive from us may be billed to and payment collected from you, an insurance company, or a third party.  For example, we may need to give your health plan information about your office visit so that your health plan will pay us or reimburse you for the visit.  We may also tell your health plan about a treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment.

For Health Care Operations:  We may use and disclose health information about you for the operations of our health care practice.  These uses and disclosures are necessary to run our practice and make sure that all of our patients receive quality care.  For example, we may use health information to review our treatment and services and to evaluate the performance of our staff in caring for you.  We may also combine health information about many patients to decide what additional services we should offer, what services are not needed, whether certain new treatments are effective, or to compare how we are doing with others and to see where we can make improvements.  We have to remove information that identifies you from this set of health information so others may use it to study health care delivery without learning the identity of our specific patients.

Appointments Reminders:  We may use and disclose health information to contact you as a reminder that you have an appointment.  Please let us know if you do not wish to have us contact you concerning your appointment, or if you wish to have us use a different telephone number or address to contact you for this purpose.

Health-Related Services and Treatment Alternatives:  We may use and disclose health information to tell you about health-related services or recommend possible treatment options or alternatives that may be of interest to you.  Please let us know if you do not wish us to send you this information, or if you wish to have us use a different address to send this information to you.

As Required By Law:  We will disclose health information about you when required to do so by federal, state or local law.

To Avert a Serious Threat to Health or Safety:  We may use and disclose health information about you when necessary to prevent or to lessen a serious or imminent threat to the health or safety of a person or the public.

Military and Veterans:  If you are a member of the armed forces or separated/discharged from military services, we may release health information about you as required by military command authorities or the Department of Veterans Affairs as may be applicable.  We may release health information about foreign military personnel to the appropriate foreign military authorities.

Workers’ Compensation:  We may release health information about you to the extent necessary to comply with laws relating to workers’ compensation or similar programs.  These programs provide benefits for work-related injuries or illness.

Public Health Risks:  We may disclose health information about you for public health activities to a public health authority or other welfare agency.  These activities generally include the following:

• to prevent or control disease, injury or disability;
• to report births and deaths;
• to report child abuse or neglect;
• to report reactions to medications or problems with FDA-regulated products or activities;
• to notify people of recalls of products they may be using;
• to notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition to the extent we are authorized to notify such a person.

Victims of Abuse, Neglect or Domestic Violence:  We may disclose protected health information about an individual whom we believe to be a victim of abuse, neglect or domestic violence to a government authority when we are required or authorized by law to do so or when you agree to the disclosure.

Health Oversight Activities:  We may disclose health information to a health oversight agency for activities authorized by law.  These activities are included for the government to monitor the health care system, government programs, and compliance with civil rights laws.

Lawsuits and Disputes:  If you are involved in a lawsuit or dispute, we may disclose health information about you in response to a court or administrative order.  We may also disclose health information about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain a protective order.

Law Enforcement:  We may release health information if asked to do so by a law enforcement official:

• in reporting certain injuries, as required by law such as gunshot wounds, burns, or any other injury caused by a gun pistol or firearm, or inflicted by a dangerous weapon other than a firearm.
• in response to a court order, subpoena, warrant, summons or similar process;
• to identify or locate a suspect, fugitive, material witness, or missing person, only the following information will be disclosed:
  • Name and address
  • Date of birth or place of birth;
  • Social security number;
  • Blood type or RH factor;
  • Type of injury;
  • Date and time of treatment and/or death, if applicable; and
  • A description of distinguishing physical characteristics.
• about a victim of a crime, if the victim agrees to disclosure or under certain limited circumstances, we are unable to obtain the person’s agreement if certain other conditions are met;
• about a death we believe may be the result of criminal conduct;
• about criminal conduct at our facility; and
• in emergency circumstances to report a crime, the location of the crime or victims, or the identity, description, or location of the person who committed the crime.

Coroners, Health Examiners and Funeral Directors:  We may release health information to a coroner or health examiner.  This may be necessary, for example, to identify a deceased person or determine the cause of death.  We may also release health information about patients to funeral directors as necessary to carry out their duties.

National Security and Intelligence Activities:  We may release health information about you to authorized federal officials for intelligence, counter-intelligence, and other national security activities authorized by law.

Protective Services for the President and Others:   We may disclose health information about you to authorized federal officials so they may provide protection to the President, other authorized persons, or foreign heads of state, or to conduct special investigations.

Inmates:  If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release health information about you to the correctional institution or law enforcement official if this release would be necessary (a) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) for the safety and security of the correctional institution.

Changes in Uses or Disclosures:  Under HIPAA, certain existing state laws may, in some facts and circumstances, prohibit uses or disclosures identified above.

YOUR RIGHTS REGARDING HEALTH INFORMATION ABOUT YOU.

You have the following rights regarding health information we maintain about you:

Right to Inspect and Copy:  You have the right to inspect and copy health information that may be used to make decisions about your care.  Usually, this includes health and billing records.

You may inspect health information that may be used to make decisions about you by requesting this information from the Privacy Officer and CEO.  You may also receive a copy of your health information by submitting your request in writing to the Privacy Officer and CEO.  If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other supplies and services associated with your request.

We may deny your request to inspect and/or copy in certain circumstances.  If you are denied access to health information, you may request that the denial be reviewed.  Another licensed health care professional chosen by our practice will review your request and the denial.  The person conducting the review will not be the person who denied your request.  We will comply with the outcome of the review.

Right to Receive Confidential Communications:  You have the right to receive confidential communications by alternative means or at alternative locations.  You must request this in writing.

Right to Amend:  If you feel that health information we have about you is incorrect or incomplete, you may ask us to amend the information.  You have the right to request an amendment for as long as we keep the information.  To request an amendment, your request must be made in writing, submitted to the Privacy Officer and CEO, and must contain one page of paper legibly handwritten or typed in at least 10 point font size.  In addition, you must provide a reason that supports your request for an amendment.

We may deny your request for an amendment if it is not in writing or does not include a reason to support the request.  In addition, we may deny your request if you ask us to amend information that:

• was not created by us, unless the person or entity that created the information is no longer available to make the amendment;
• is not part of the health information kept by or for our practice;
• is not otherwise available for inspection; or
• is accurate or complete.

Any amendment we make to your health information will be disclosed to those with whom we disclose information as previously specified.

Right to an Accounting of Disclosures:  You have the right to request a list accounting for any disclosures of your health information we have made, except for uses and disclosures for treatment, payment, and health care operations, as previously described.

To request this list of disclosures, you must submit your request in writing to the Privacy Officer and CEO.  Your request must state a time period which may not be longer than six years.  The first list you request within a 12 month period will be free.  For additional lists, we may charge you for the costs of providing the list.  We will notify you of the cost involved and you may choose to withdraw or modify your request at that time, before any costs are incurred.  We will mail you a list of disclosures in paper form within 30 days of your request, or notify you if we are unable to supply the list within that time period and by what date we can supply the list; but this date will not exceed a total of 60 days from the date you made the request.

Right to Request Restrictions:  You have the right to request a restriction or limitation on the health information we use or disclose about you for treatment, payment, or health care operations.  You also have the right to request a limit on the health information we disclose about you to someone who is involved in your care or the payment for your care, such as a family member or friend.  For example, you could ask that we restrict a specified nurse from use of your information, or that we not disclose information to your spouse about a surgery you had.

We are not required to agree to your request for restrictions if it is not feasible for us to ensure our compliance or believe it will negatively impact the care we may provide you.  If we do agree, we will comply with your request unless the information is needed to provide you with emergency treatment.  To request a restriction, you must make your request in writing to the Privacy Officer and CEO.  In your request, you must tell use what information you want to limit and to whom you want the limits to apply; for example, use of any information by a specified nurse, or disclosure of a specified surgery to your spouse.

Right to a Paper Copy of This Notice:  You have a right to obtain a paper copy of this notice at any time.  To obtain a copy, please request it from the Privacy Officer and CEO.

You may also obtain a copy of this notice either from our website (www.dermatologyconsultants.com) or by requesting a copy of this notice be sent through electronic mail to.  If we know that the electronic message has failed to be delivered, a paper copy of the notice will be provided.  Even if you have received a notice electronically, you still retain the right to receive a paper copy upon request.

If the first service delivery is delivered electronically, other than by telephone, we provide electronic notice in the same medium, automatically and contemporaneously in response to a first request for service.

CHANGES TO THIS NOTICE

We reserve the right to change this notice.  We reserve the right to make the revised or changed notice effective for health information we already have about you as well as any information we receive in the future.  We will post a copy of the current notice in our facility.  The notice will contain on the first page, in the top right-hand corner, the effective date.  In addition, each time you register for treatment or health care services, we will offer you a copy of the current notice in effect.

COMPLAINTS

If you believe your privacy rights have been violated, you may file a complaint with us or with the Secretary of the Department of Health and Human Services.  To file a complaint with us, contact the Privacy Officer and CEO.  All complaints must be submitted in writing.  You will not be penalized for filing a complaint.

OTHER USES OF HEALTH INFORMATION

Other uses and disclosures of health information not covered by this notice or the laws that apply to us will be made only with your written permission.  If you provide us permission to use or disclose health information about you, you may revoke that permission, in writing, at any time.  If you revoke your permission, we will no longer use or disclose health information about you for the reasons covered by your written authorization.  You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provided you.

Acknowledgement of Receipt of This Notice

We will request that you sign a separate form or notice acknowledging you have received a copy of this notice.  If you are not able to sign, a staff member will sign their name, and date.  This acknowledgement will be filed with your records.