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  • HIPAA Patient Form

    The following is a required "notice of privacy practices" (NPP) in keeping with Federal and State HIPAA requirements.
  • Overview of privacy issues:

  • The laws regarding privacy of personal health information are complicated. Federal regulations require your approval of a full NPP as part of receiving health services. To accomplish this, I will provide you with a copy of the full, legally required NPP and this shorter version, which summarizes the same information. Finally, there is a standard consent form that documents your agreement with the NPP. I am not permitted to provide treatment without an executed consent form. You also may have additional questions or concerns, including about situations not covered by this information, and you are encouraged to voice these. The health information in your records will be mainly used to provide treatment, to arrange payment for services, and for some other business activities that are called, in the law, "health care operations." Before private information can be disclosed (sent, shared, or re1eased) for any additional purposes, a separate authorization form is required to allow it.
  • Your health information is private and will be kept that way, but there are some times when the law requires disclosure. For example:
    1. When there is a serious threat to your health or safety or the health or safety of another individual or the public. Information would then be shared with a person or organization that is able to help prevent or reduce the threat.
    2. Some lawsuits and legal or court proceedings.
    3. If a law enforcement official requires to do so.
    4. For Workers Compensation and similar benefit programs.
    5. There are some other situations like these but which happen very rarely. They are described in the longer version of the NPP.
  • Your rights regarding your health information:

    1. You can ask me to communicate with you about your health and related issues in a particular way or at a certain place for more privacy. For example, you could ask me to call you at home and not a work to schedule or cancel an appointment. I will try my best to do as you ask.
    2. You can request that I limit what is disclosed to any people who are involved in your treatment or the payment for treatment, such as family members or friends. If I agree to the request, I would attempt to keep that agreement except if it is against the law, or in an emergency, or when the information is necessary to treat you.,
    3. You have the right to look at your health information, such as billing records or health records associated with your skin care. You can even get a copy of these, provided that you reimburse your provider for time and copy expenses involved.
    4. If you believe that any information in your records is incorrect or missing important information, you can ask to have some kinds of changes (termed "amending") to your health information. You would have to make such a request in writing and send it to the office, and you would also need to write the reasons that you want to make the changes.
    5. You have the right to a copy of this notice and to the longer NPP. If I make any changes to either form, I will post the new version in the waiting room, and you could always get a copy of the new NPP from me.
    6. You have the right to file a complaint if you believe that your privacy rights have been violated.
  • You can file such a complaint with me personally and with the Secretary of the Department of Health and Human Services. All complaints must be in writing. Filing a complaint regarding privacy will not in itself change the health care that you receive at this office. If you have any questions regarding this notice or the health information privacy policies at this office, please contact Skin Deep, or go to https://www.hhs.gov/hipaa/for-professionals/faq/index.html to find out more information.
  • I have read and understand the above Notice.
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