Privacy Policy

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HIPAA PRIVACY RULE OF PATIENT AUTHORIZATION AGREEMENT

Authorization for the Disclosure of Protected Health Information for Treatment, Payment, or Healthcare Operations (§164.508(a))

I understand that as part of my healthcare, this facility originates and maintains health records describing my health history, symptoms, examination and test results, diagnosis, treatment and any plans for future care or treatment. I understand that this information serves as:

• a basis for planning my care and treatment;
• a means of communication among the health professionals who may contribute to my healthcare;
• a source of information for applying my diagnosis and surgical information to my bill;
• a means by which a third-party payer can verify that services billed were actually provided;
• a tool for routine healthcare operations such as assessing quality and reviewing the competence of healthcare professionals

I have been provided with a copy of the Notice of Privacy Practices that provides a more complete description of information uses and disclosures.

I understand that as part of my care and treatment it may be necessary to provide my Protected Health Information to another covered entity. I have the right to review this facility’s notice prior to signing this authorization. I authorize the disclosure of my Protected Health Information as specified below for the purposes and to the parties designated by me.

HIPAA PRIVACY RULE OF PATIENT CONSENT AGREEMENT

Consent to the Use and Disclosure of Protected Health Information for Treatment, Payment, or Healthcare Operations (§164.506(a))

I understand that:

• I have the right to review this facility’s Notice of Information practices prior to providing my consent
• This facility reserves the right to change the notice and practices and that prior to implementation will mail a copy of any revised notice to the address I’ve provided if requested
• I have the right to request restrictions as to how my protected health information may be used or disclosed to carry out treatment, payment, or healthcare operations and that this facility is not required by law to agree to the restrictions requested
• I may revoke my consent in writing at any time, except to the extent that this facility has already taken action in reliance thereon
• It is this facility’s procedure to share Protected Health Information with labs, x-rays, consulting physicians, and hospitals. We will call the pharmacy of your choice regarding your prescriptions. We will only exchange minimum necessary Protected Health Information for each transaction

Crossroads Dermatology’s Privacy Policy

When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.

 

Get an electronic or paper copy of your medical record

  •  You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this.
  •  We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.

Ask us to correct your medical record

  •  You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this.
  •  We may say “no” to your request, but we’ll tell you why in writing within 60 days.

Request confidential communications

  •  You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.
  •  We will say “yes” to all reasonable requests.
 

Your Rights. Our Responsibilities.

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

Ask us to limit what we use or share

  •  You can ask us not to use or share certain health information for treatment, payment, or our operations.
  •  We are not required to agree to your request and we may say “no” if it would affect your care.
  •  If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer.
  •  We will say “yes” unless a law requires us to share that information.

Get a list of those with whom we’ve shared information 

  •  You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why.
  •  We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.

Get a copy of this privacy notice 

  •  You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.

Choose someone to act for you 

  •  If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.
  •  We will make sure the person has this authority and can act for you before we take any action.

File a complaint if you feel your rights are violated 

  •  You can complain if you feel we have violated your rights by contacting us using the information on our contact page.
  •  You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting http://www.hhs.gov/ocr/privacy/hipaa/complaints/
  •  We will not retaliate against you for filing a complaint.
 

Your choices for certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.

In these cases, you have both the right and choice to tell us to:

  •  Share information with your family, close friends, or others involved in your care
  •  Share information in a disaster relief situation
  •  Include your information in a hospital directory

In these cases, we never share your information unless you give us written permission. This includes: 

  •  Marketing purposes
  •  Sale of your information

We typically use your health information in the following ways:

To treat you:

  •  We can use your health information and share it with other professionals who are treating you. Example: A doctor treating you for an injury asks another doctor about your overall health condition.

To run our practice: 

  •  We use and share your health information to run our practice, improve your care, and contact you when necessary. Example: We use health information about you to manage your treatment and services.

To bill for services:

  •  We use and share your health information to bill and get payment from health plans or other entities.  Example: We give information about you to your health insurance plan so it will pay for your services.

To help with public health and safety issues:

We can share health information about you for certain situations such as:

  •  Preventing disease
  •  Helping with product recalls
  •  Reporting adverse reactions to medications
  •  Reporting suspected abuse, neglect, or domestic violence
  •  Preventing or reducing a serious threat to anyone’s health or safety

To do research 

  •  We can use or share your information for health research.

To comply with the law

  •  We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law.

To respond to organ and tissue donation requests:

  •  We can share health information about you with organ procurement organizations.

To work with a medical examiner or funeral director

  •  We can share health information with a coroner, medical examiner, or funeral director when an individual dies.

To address workers’ compensation, law enforcement, and other government requests

  •  We can use or share health information about you:
  •  For workers’ compensation claims
  •  For law enforcement purposes or with a law enforcement official
  •  With health oversight agencies for activities authorized by law
  •  For special government functions such as military, national security, and presidential protective services

To respond to lawsuits and legal actions 

  •  We can share health information about you in response to a court or administrative order, or in response to a subpoena.
  •  We are required by law to maintain the privacy and security of your protected health information.
  •  We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
  •  We must follow the duties and privacy practices described in this notice and give you a copy of it.

How else can we use or share your health information?

We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes.

For more information see http://www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html

We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.

For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html