Patient Forms

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Notice of Health Information Privacy Practices

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.

We are required by law to provide you with this notice that explains our privacy practices with regard to your medical information and how we may use and disclose your protected health information for treatment, payment, and for health care operations, as well as for other purposes that are permitted or required by law. You should know that you have certain rights regarding the privacy of your protected health information and we describe them in this notice.

Ways in Which We May Use and Disclose Your Protected Health Information

The following paragraphs describe different ways that we use and disclose your protected health information. We have provided an example for each category, but these examples are not meant to be exhaustive. We assure you that all of the ways we are permitted to use and disclose your health information fall within one of these categories.

Treatment. We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. We will also disclose your health information to other physicians who may be treating you. Additionally we may from time to time disclose your health information to another physician who we have requested to be involved in your care. For example, we would disclose your health information to a specialist to whom we have referred you for a diagnosis or opinion to help in your treatment.

Payment. We will use and disclose your protected health information to obtain payment for the health care services we provide you. For example, we may include information with a bill to a third-party payer that identifies you, your diagnosis, procedures performed, and supplies used in rendering the service.

Health Care Operations. We will use and disclose your protected health information to support the business activities of our practice. For example, we may use medical information about you to review and evaluate our treatment and services or to evaluate our staff’s performance while caring for you. In addition, we may disclose your health information to third party business associates who perform billing, consulting, or transcription services for our practice.

Other Ways We May Use and Disclose Your Protected Health Information

Appointment Reminders. We will use your protected health information to contact you or mail you a reminder about scheduled appointments or treatments.

Treatment or Service Alternatives. We will use and disclose your protected health information to provide you with information about or to recommend possible alternative treatments or other services that may be of interest to you.

Others Involved in Your Care. When necessary, we will use and disclose your protected health information to a family member, a relative, a close friend, or any other person you identify who is involved in your medical care or payment for care.

Research. We will use and disclose your protected health information to researchers provided the research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your health information.

As Required by Law. We will use and disclose your protected health information when required to by federal, state, or local law. You may request an accounting of such disclosures at any time (refer to An Accounting of Disclosures paragraph for details).

To Avert a Serious Threat to Public Health or Safety. We will use and disclose your protected health information to a public health authority that is permitted to collect or receive the information for the purpose of controlling disease, injury, or disability. If directed by that health authority, we will also disclose your health information to a foreign government agency that is collaborating with the public health authority.

Worker’s Compensation. We will use and disclose your protected health information for worker’s compensation or similar programs that provide benefits for work-related injuries or illness in accordance with state law.

Inmates. We will use and disclose your protected health information to a correctional institution or law enforcement official if you are an inmate of that correctional institution or under the custody of the law enforcement official. This information would be necessary for the institution to provide you with health care; to protect the health and safety of others; or for the safety and security of the correctional institution.

Your Health Information Rights

Although your health record is the physical property of this health care practitioner, the information belongs to you. You have the right to:

A Paper Copy of This Notice. You have the right to receive a paper copy of this notice. If we have not already provided you with a copy, you may obtain a copy by asking our receptionist at your next visit or by calling and asking us to mail you a copy.

Inspect and Copy. You have the right to inspect and obtain a copy the protected health information that we maintain about you in our designated record set for as long as we maintain that information. This designated record set includes your medical and billing records, as well as any other records we use for making decisions about you. You may request an electronic copy of your information in a form you specify; however, if we are not able to provide the information in the form requested, we must contact you to determine a suitable alternative. Any psychotherapy notes that may have been included in records we received about you are not available for your inspection or copying by law. We may charge you a fee for the costs of copying, mailing, or other supplies used in fulfilling your request.

If you wish to inspect or copy your medical information, you must submit your request in writing to our Practice Manager at SKINPros, LLC, 1287 North Main St. Providence RI 02904. You may mail in your request, or bring it to our office. We will have 30 days to respond to your request for information that we maintain at our practice site. If the information is stored off-site, we are allowed an additional 30 days to respond but must inform you of this delay in writing.

Request Amendment. You have the right to request that we amend your medical information if you feel that it is incomplete or inaccurate. You must make this request in writing to our practice manager, stating exactly what information is incomplete or inaccurate, and your reasoning that supports your request.

We are permitted to deny your request if it is not in writing or if it does not include a reason to support the request. By law, we may also deny your request if:

  • the information was not created by us, or the person who created it is no longer available to address the requested amendment;
  • the information is not part of the records which you are permitted to inspect and copy;
  • the information is not part of the designated record set kept by this practice; or
  • if it is the opinion of the health care provider that the information is accurate and complete.

Request Restrictions. You have the right to request a restriction or limitation of how we use or disclose your medical information for treatment, payment, or health care operations. For example, you could request that we not disclose information to your insurance carrier about a treatment that you paid for in full out of pocket. Your request must be made in writing to our practice manager.

Other than as in the example above, we are not required to agree to your request if we feel it is in your best interest to disclose that information. However, if we do agree, we will comply with your request unless that information is needed for emergency treatment.

An Accounting of Disclosures. You have the right to request a list of the disclosures of your health information we have made outside of our practice that were not for treatment, payment, or health care operations.