Prime Dermatology
Privacy Policy
This notice describes how Prime Dermatology uses and discloses your protected health information, your rights as a patient, and how to file a privacy complaint. Review the details below and sign to acknowledge receipt.
Acknowledgement of Receipt of Notice of Privacy Practices
In connection with the medical services that I am receiving from Prime Dermatology and its medical staff, I hereby authorize Prime Dermatology, the above-named practitioner, and their respective agents to disclose any and all information concerning my medical condition and treatment (including, but not limited to, superconfidential information concerning sexually transmitted diseases, mental health, chemical dependence, DNA samples or analyses, or other such information), including copies of applicable hospital and medical records to: any third party payor covering the medical services of the patient; other health care professionals and institutions involved in the delivery of health care to the patient; The proponent of any legally sufficient subpoena, or in response to a court order; Employees and agents of the practice, to the degree necessary to facilitate the provision of health care operations, services and payment for such services; Pharmacies; and As otherwise required by law.
I further consent that photographs may be taken of me or parts of my body, under the following conditions:
- The photographs may be taken only with the consent of my practitioner and under such conditions and at such times as may be approved by my provider.
- The photographs shall be taken by my practitioner or by a photographer approved by my physician.
When providing information to me, information may be transmitted to me by any or all of the following means:
- Telephone messages on an answering machine
- Primary email on file
- Text message
In each case, the practice shall take reasonable steps to ensure that only the minimum necessary information is disclosed in accordance with the above.
I acknowledge that I have received a copy of the ‘Privacy Policy’ from Prime Dermatology. This Notice describes how Prime Dermatology may use and disclose my protected health information, certain restrictions on the use and disclosure of my healthcare information, and rights I may have regarding my protected health information.
If you believe your privacy rights have been violated, it is your right to file a formal complaint with Prime Dermatology and/or the U.S. Department of Health and Human Services.
For more information, please contact the U.S. Department of Health and Human Services at 1-800-368-1019.
This consent is valid from the date executed until revoked in writing by the patient
