Notice of Privacy Practices for Dermatology Practice

[Practice Name] Dermatology

Effective Date: [Date]

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.

Our Commitment to Your Privacy

Our dermatology practice is dedicated to maintaining the privacy of your medical information. We are required by law to maintain the confidentiality of health information that identifies you. We are also required by law to provide you with this notice of our legal duties and privacy practices.

How We May Use and Disclose Your Medical Information

Treatment

• Consulting with other healthcare providers about your care
• Scheduling and coordinating procedures
• Prescribing medications
• Sharing information with laboratories

Payment

• Billing and collections
• Insurance claims and coverage verification
• Prior authorizations for procedures

Healthcare Operations

• Quality assessment activities
• Employee review activities
• Training medical students
• Compliance and auditing functions

Your Rights Regarding Your Medical Information

1. Right to Inspect and Copy
2. Right to Amend
3. Right to an Accounting of Disclosures
4. Right to Request Restrictions
5. Right to Confidential Communications
6. Right to a Paper Copy of This Notice

Changes to This Notice

We reserve the right to change this notice. We will post a copy of the current notice in our facility with the effective date.

Complaints

If you believe your privacy rights have been violated, you may file a complaint with our practice or with the Secretary of the Department of Health and Human Services.

Contact Information

Practice Privacy Officer: [Name] Phone: [Phone Number] Address: [Practice Address]

By signing below, I acknowledge that I have received a copy of this Notice of Privacy Practices.

Signature: _________________________ Date: _____________