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Personal Health Information Page

THIS NOTICE DESCRIBES HOW INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

1. Information about you, your condition and other personal information will be collected in the input form through our Patient Portal for the purposes of properly scheduling and addressing your condition and/or desire for dermatology treatment.

2. This information will be used for the purposes of scheduling, treatment and follow up. The initial authorization for this use will require your authorization (as noted by clicking on the I Authorize This Use button on the form in the patient portal and/or the input form on our tablets in the offices.

3. Other uses and disclosures will be made only with the individual’s written authorization and that the individual may revoke such authorization

4. When applicable, separate statements that the covered entity may contact you, the individual being seen/treated to provide appointment reminders or information about treatment alternatives and other health-related benefits and services that may be of interest to the individual; or to raise funds for the covered entity, the group health plan or health insurance issuer or health maintenance organization may disclose PHI (Personal Health Information) to the sponsor of the plan.

5. You have the right to authorize or refuse authorization for the use of this information at any time.

  • The right to request restrictions on certain uses and disclosures as provided by 45 CFR 164.522(a), including a statement that the covered entity is not required to agree to a requested restriction and (b) those services for which the individual has paid him- or herself.
  • The right to receive confidential communications of PHI as provided by 164.522(b), as applicable.
  • The right to inspect and copy PHI as provided by 164.524.
  • The right to amend PHI as provided in 164.526.
  • The right to receive an accounting of disclosures as provided in 164.528.
  • The right to obtain a paper copy of the notice upon request as provided in 164.520.

6. A statement that the covered entity is required by law to maintain the privacy of PHI and to provide individuals with a notice of its legal duties and privacy practices with respect to PHI.

7. A statement that the covered entity is required to abide by the terms of the notice currently in effect.

8. A statement that the covered entity reserves the right to change the terms of its notice and to make the new notice provisions effective for all PHI that it maintains.

9. A statement describing how the covered entity will provide individuals with a revised notice.

10. A statement that individuals may complain to the covered entity and to the Secretary of Health and Human Services if they believe their privacy rights have been violated; a brief description of how one files a complaint with the covered entity; and a statement that the individual will not be retaliated against for filing a complaint.

11. For further information about this contact.

12. This is effective as of January 1, 2016.