HIPAA

Our office complies with the Health Insurance Portability and Accountability Act to ensure that all of our patients' information is kept properly confidential. Unless you notify us otherwise, we may use and disclose your medical records ONLY for the purposes of treatment (as regards coordination of your care with other providers and services), and payment (as regards obtaining reimbursement for services, confirming coverage and billing your insurance company) and health care operations. We may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services. Unless otherwise notified by you, we may at times leave a message at your home phone answering machine, with a family member, or mail information to your home address regarding your medical information.

Please list any other parties who can have access to your health information (this includes step parents, grandparents, and any caretakers who can have access to this patient's records)

The undersigned acknowledges receipt of a copy of the currently effective notice of privacy practices for Windsor Dermatology, PC and The Psoriasis Treatment Center of Central New Jersey. I understand that my personal information will only be used and/or disclosed as above, and that I have the right to request restrictions concerning then use of my personal information. A copy of this signed, dated document shall be as effective as the original. My signature will also serve as a PHI document release should I request treatment/medical records be sent to other attending doctors/facilities in the future.

You may refuse to sign this acknowledgement and authorization. In refusing, we may not be allowed to process your insurance claims.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

CONSENT TO OBTAIN EXTERNAL PRESCRIPTION HISTORY

I authorize Windsor Dermatology, PC and The Psoriasis Treatment Center of Central New Jersey to view my external prescription history via the Rxhub service of SureScripts. I understand that prescription history from multiple other unaffiliated medical providers, insurance companies, and pharmacy benefit managers may be viewable by my providers and staff here, and it may include prescriptions back in time for several years. My signature certifies that I read and understood the scope of my consent and that I authorize access.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.