DERMATOLOGY CENTER OF ROCKLAND, P.C.

This summary of our privacy practices contains a condensed version of our Notice of Privacy Practices. Our full-length Notice is posted and a copy is available to you.

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 understand that your medical information is personal to you, and we are committed to protecting the information about you. As our patient, we create medical records about your health, our care for you, and the services and/or items we provide to you as our patient. By law, we are required to make sure that your Protected Health Information is kept private.

How will we use or disclose your information? Here are a few examples (for more detail please refer to the Notice of Privacy Practices that is available to you):

For medical treatment
To obtain payment for our services
In emergency situations
For appointment and patient recall reminders
To run our Practice more efficiently and ensure all our patients receive quality care

For research
To avert a serious threat to health or safety
For organ and tissue donation
For workers' compensation programs
In response to certain requests arising out of lawsuits or other disputes

If you believe your privacy rights have been violated, you may file a complaint with the Practice or with the Secretary of the Department of Health and Human Services. To file a complaint with the Practice, contact our office manager. All complaints must be submitted in writing. You will not be penalized for filing a complaint.

You have certain rights regarding the information we maintain about you. These rights include:

The right to inspect and copy
The right to amend
The right to an accounting of disclosures

The right to request restrictions
The right to a paper copy of this notice
The right to request confidential communications

For more information about these rights, please see the detailed Notice of Privacy Practices.

Patient Consent and Acknowledgment

Patient Name

Date of Birth

I hereby acknowledge that I have had the right to review Dermatology Center of Rockland (the “Practice”) Privacy Policy (the “Notice”) prior to signing this Patient Consent and Acknowledgement and that I hereby agree to the terms set forth therein.

By signing this form,

(i) I hereby consent to the Practice calling the phone numbers designated by me below or provided by me to the Practice to provide appointment information, results, medical consults and other contact relating to my protected health information (“PHI”). I also consent to the Practice leaving me a message on any of the designated numbers below or provided by me to the Practice to provide appointment information, results, medical consults and other contact relating to my PHI.

(ii) I hereby consent to the Practice sending mail to any physical address I hereby provided to the Practice.

(iii) I hereby consent to the Practice e-mailing me at any email address provided below or provided by me to the Practice. I understand I may revoke my consent in writing except to the extent that the Practice has already made disclosures in reliance upon my prior consent. If I do not sign this consent I understand that the Practice may decline to provide treatment to me.

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.

Patient Signature

Date

Parent or Legal Guardian Signature

Date

Phone Number (s): Cell:

Work/Other

Home

Email address

Formatted text

To Be Completed By Covered Entity If Unable To Obtain Written Acknowledgement from Patient

I attempted to obtain a written acknowledgement of receipt of the Notice of Privacy Practices from the above named patient, but was unable to because:

Patient did not understand the request to sign the Written Acknowledgement

Patient declined to sign this Written Acknowledgement

Other (specify)

PATIENT COMMUNICATION FORM

A. FRIENDS AND FAMILY. It is the office policy of Dermatology Center of Rockland, P.C. not to release confidential medical information regarding your treatment to family members or friends, except for (i) parent/legal guardian, (ii) other persons authorized by the patient, (iii) as we may reasonably infer from the circumstances (for example, if you bring a family member or friend into the exam room, we will assume, unless you object, that that person is entitled to receive information regarding your treatment), (iv) in emergency situations, or (v) other as otherwise permitted by the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

If you anticipate that you will need or want your medical information to be provided to family members, friends, or caretakers/babysitters, please indicate that below, so that we may best serve you. By signing below, you authorize the following people to receive information regarding your treatment or care. (If you wish to add names later on, please confirm this in writing, or call our staff.)

Add Person

B. Alternative Communications. You are also entitled to specify alternative, reasonable means of communication, if you do not wish to be contacted by us in a certain way.

I hereby request the following means of contact only

NAME

Patient/Parent/Guardian Signature

Date

************************************************************************************************************************

Legal Guardian Treatment Permission

As the legal guardian of

I give permission to the Dermatology Center of Rockland, P.C. to treat the patient without my presence at the time of treatment.

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.

Signature of Legal Guardian

Patient’s Name

Name of Legal Guardian

Date

************************************************************************************************************************

FOR OFFICE USE

Changes to above authorized by patient over phone:

Add Item

HIPAA RELATED PROVISIONS

USING THE PATIENT’S NAME IN THE WAITING ROOM

I, understand that, by signing the HIPAA form, I give permission to the staff of the Dermatology Center of Rockland, PC, to call my name in the waiting room when verifying my information or calling me back to the examination room.

Patient Signature

Date

Parent/Guardian Signature (if applicable)

Date

LEAVING DETAILED MESSAGES ON TELEPHONE

In an effort to increase efficiency within the office, the Dermatology Center of Rockland, PC, would like to gain your permission to leave detailed information on your telephone if they must contact you for lab results, medication refills, or for other reasons. Please check off your preference below:

In the event that I am unavailable when the staff attempts to return my call, I give permission for the staff to leave a voicemail at my

Home Number

Cell Number

Other Number

I do not give permission to the Dermatology Center of Rockland, PC, to leave a voicemail on my telephone if I am unavailable when they attempt to contact me.

Patient Signature

Date

Parent/Guardian Signature (if applicable)

Date

Your information will be encrypted.