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NOTICE OF 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.

 

A. OUR COMMITMENT TO YOUR PRIVACY

This notice applies to all practices doing business under QualDerm
Management and includes all affiliated practices.

We are dedicated to maintaining the privacy of your protected health
information (PHI). In conducting our business, we will create records
regarding you and the treatment and services we provide to you. We are
required by law to maintain the confidentiality of health information that
identifies you. We also are required by law to provide you with this notice of
our legal duties and the privacy practices that we maintain in our practice
concerning your PHI. By federal and state law, we must follow the terms of
the Notice of Privacy Practices that we have in effect at the time your care or
treatment was provided. We are also required to notify you if your information
has been compromised.

This Notice of Privacy Practices describes how we may use and disclose your
PHI to carry out treatment, payment or health care operations and for other
purposes that are permitted or required by law. It also describes your rights
to access and control your PHI. PHI is information about you, including
demographic information, that may identify you and that relates to your past,
present or future physical or mental health condition and related health care
services. This notice applies to all of the records of your care and billing for
care that are created or maintained by us.

The terms of this notice apply to all records containing your PHI that are
created or retained by us. We reserve the right to revise or amend this Notice
of Privacy Practices. Any revision or amendment to this notice will be
effective for all of your records that we have created or maintained in the
past, and for any of your records that we may create or maintain in the future.
We will post a copy of our current notice in our offices in a visible location at
all times. You may view a copy of our most current notice at any time by
accessing our website: https://www.qualderm.com/

B. WE MAY USE AND DISCLOSE YOUR PHI IN THE FOLLOWING WAYS:

The following categories describe the different ways in which we may use and
disclose your PHI.

1. Treatment. We may use your PHI to treat you. For example, we may ask
you to have laboratory tests (such as blood or urine tests), and we may
use the results to help us reach a diagnosis. We might use your PHI in
order to write a prescription for you, or we might disclose your PHI to a
pharmacy when we order a prescription for you. Many of the people who
work for our practice, including but not limited to, our doctors and nurses
may use or disclose your PHI in order to treat you or to assist others in
your treatment. Finally, we may also disclose your PHI to other health care
providers for purposes related to your treatment.

2. Payment. We may use and disclose your PHI in order to bill and collect
payment for the services and items you may receive from us. For
example, we may contact your health insurer to certify that you are eligible
for benefits (and for what range of benefits), and we may provide your
insurer with details regarding your treatment to determine if your insurer
will cover, or pay for, your treatment. We also may use and disclose your
PHI to obtain payment from third parties that may be responsible for
payment for your care, such as family members. Also, we may use your
PHI to bill you directly for services and items. We may disclose your PHI
to other health care providers and entities to assist in their billing and
collection efforts.

3. Health Care Operations. We may use and disclose your PHI to operate
our business. For example, we may use and disclose your information for
our operations, our practice may use your PHI to evaluate the quality of
care you received from us, or to conduct cost-management and business
planning activities for our practice. We may disclose your PHI to other
health care providers and entities to assist in their health care operations.
We may disclose your PHI to medical school students, residents or fellows
that see patients at our office. We may also call you by name in the
waiting room when your physician is ready to see you. We will share your
PHI with third-party “business associates” that perform various activities
(e.g., billing, computer services) for the practice. Whenever an
arrangement between our office and a business associate involves the use
or disclosure of your PHI, we will have a written contract that contains
terms that will protect the privacy of your PHI.

4. Appointment Reminders. We may use and disclose your PHI to contact
you and remind you of an appointment. We will leave a message for you
at any telephone number you give us stating the time of the appointment
and the name of the person with whom you have the appointment unless
we have agreed in writing to your written request to handle appointment
reminders differently.

5. Treatment Options. We may use and disclose your PHI to inform you of
potential treatment options or alternatives.

6. Health-Related Benefits and Services. We may use and disclose your PHI
to inform you of health-related benefits or services that may be of interest
to you. We may use or disclose your PHI, as necessary, to provide you
with information about treatment alternatives or other health-related
benefits and services that may be of interest to you. We do not “sell” your
PHI to other individuals or companies.

7. Release of Information to Family/Friends. We may disclose your PHI to a
friend or family member that is involved in your care, or who assists in
taking care of you. Only information that is relevant to their role in your
care will be disclosed.

8. Research. We may use and disclose your PHI for research purposes in
certain research studies, but only when they meet all federal and state
requirements to protect your privacy, such as using de-identified data
when possible. You may also be contacted to participate in a research
study.

9. Emergencies. We may use or disclose your PHI in an emergency
treatment situation. If this happens, we will try to obtain your authorization
as soon as reasonably practicable after the delivery of treatment. If we are
required by law to treat you and have attempted to obtain your
authorization but are unable to do so, we may still use or disclose your PHI
to treat you.

10. Communication Barriers. We may use and disclose your PHI if your
physician or another physician in the practice attempts to obtain consent
from you but is unable to do so due to substantial communication barriers,
and the physician determines, using professional judgment, that you intend
to consent to use or disclosure under the circumstances.

C. USE AND DISCLOSURE OF YOUR PHI IN CERTAIN SPECIAL
CIRCUMSTANCES REQUIRED BY LAW

We will use and disclose your PHI when we are required to do so by federal,
state or local law.

D. USE AND DISCLOSURE OF YOUR PHI IN CERTAIN SPECIAL
CIRCUMSTANCES PERMITTED BY LAW

The following categories describe unique scenarios in which we may use or
disclose your identifiable health information:

1. Public Health Risks. We may disclose your PHI to public health authorities
that are authorized by law to collect information for the purpose of:
• Maintaining vital records, such as births and deaths
• Reporting child abuse or neglect
• Preventing or controlling disease, injury or disability
• Notifying a person regarding potential exposure to a communicable
disease
• Notifying a person regarding a potential risk for spreading or contracting
a disease or condition
• Reporting reactions to drugs or problems with products or devices
• Notifying individuals if a product or device they may be using has been
recalled
• Notifying appropriate government agency(ies) and authority(ies)
regarding the potential abuse or neglect of an adult patient (including
domestic violence); however, we will only disclose this information if the
patient agrees or we are required or authorized by law to disclose this
information.

2. Health Oversight Activities. We may disclose your PHI to a health
oversight agency for activities authorized by law. Oversight activities can
include, for example, investigations, inspections, audits, surveys, licensure
and disciplinary actions; civil, administrative, and criminal procedures or
actions; or other activities necessary for the government to monitor
government programs, compliance with civil rights laws and the health
care system in general.

3. Lawsuits and Similar Proceedings. We may use and disclose your PHI in
response to a court or administrative order, if you are involved in a lawsuit
or similar proceeding. We also may disclose your PHI in response to a
discovery request, subpoena, or other lawful process by another party
involved in the dispute, but only if we have made an effort to inform you of
the request or to obtain an order protecting the information the party has
requested.

4. Law Enforcement. We may release PHI if asked to do so by a law
enforcement official:
• Regarding a crime victim in certain situations, if we are unable to obtain
the person’s agreement
• Concerning a death we believe has resulted from criminal conduct
• Regarding criminal conduct at our offices
• In response to a warrant, summons, court order, subpoena or similar
legal process
• To identify/locate a suspect, material witness, fugitive or missing person
• In an emergency, to report a crime (including the location or victim(s) of
the crime, or the description, identity or location of the perpetrator)

5. Deceased Patients. We may release PHI to a medical examiner or
coroner to identify a deceased individual or to identify the cause of death.
If necessary, we also may release information in order for funeral directors
to perform their jobs. We may disclose deceased individuals’ PHI to nonfamily members, as well as family members, who were involved in the care
or payment for health care of the decedent prior to death; however, any
disclosure is limited to PHI relevant to such care or payment and will not
be inconsistent with any prior expressed preference of the deceased
individual.

6. Research. The practice may use and disclose your PHI for research
purposes in certain limited circumstances. We will obtain your written
authorization to use your PHI for research purposes except when an
Institutional Review Board or Privacy Board has given approval to waive
your authorization.

7. Serious Threats to Health or Safety. The practice may use and disclose
your PHI when necessary to reduce or prevent a serious threat to your
health and safety or the health and safety of another individual or the
public. Under these circumstances, we will only make disclosures to a
person or organization able to help prevent the threat.

8. Military. We may disclose your PHI if you are a member of U.S. or foreign
military forces and if required by the appropriate authorities.

9. National Security. The practice may disclose your PHI to federal officials
for intelligence and national security activities authorized by law. We may
also disclose your PHI to federal officials in order to protect the President,
other officials or foreign heads of state, or to conduct investigations.

10. Inmates. The practice may disclose your PHI to correctional institutions or
law enforcement officials if you are an inmate or under the custody of a law
enforcement official. Disclosure for these purposes would be necessary:
(a) for the institution to provide health care services to you, (b) for the
safety and security of the institution, and/or (c) to protect your health and
safety or the health and safety of other individuals.

E. YOUR RIGHTS REGARDING YOUR PHI

You have the following rights regarding the PHI that we maintain about you:

1. Confidential Communications. You have the right to request that we
communicate with you about your health and related issues in a particular
manner or at a certain location. For example, you may ask that we contact
you at home, rather than work. To request a type of confidential
communication please contact the Privacy Officer at (615) 250-6727. You
will need to specify the requested method of contact, or the location where
you wish to be contacted. You do not need to give a reason for your
request. We may ask you to put your request in writing. We will
accommodate reasonable requests.

2. Requesting Restrictions. You have the right to request a restriction in our
use or disclosure of your PHI for treatment, payment or health care
operations. Additionally, you have the right to request that we restrict our
disclosure of your PHI to only certain individuals involved in your care or
the payment for your care, such as family members and friends. We are
not required to agree to your request; except in the event that you request
we restrict information from your health plan for a service or product that
was paid for out-of-pocket. In other circumstances, if we do agree, we are
bound by our agreement except when otherwise required by law, in
emergencies, or when the information is necessary to treat you. Please
contact the Privacy Officer at (615) 250-6727 for assistance in completing
your request.

3. Inspection and Copies. You have the right to inspect and obtain a copy of
the PHI that may be used to make decisions about you, including patient
medical records and billing records. Please submit your request at the
location where you received services.

4. Amendment. You may ask us to amend your health information if you
believe it is incorrect or incomplete, and you may request an amendment
for as long as the information is kept by or for our practice. To request an
amendment, please contact the Privacy Officer at (615) 250-6727. You
must provide us with a reason that supports your request for amendment.
We may deny your request if you ask us to amend information that is in our
opinion: (a) accurate and complete; (b) not part of the PHI kept by or for
the practice; (c) not part of the PHI which you would be permitted to
inspect and copy; or (d) not created by our practice, unless the individual
or entity that created the information is not available to amend the
information.

5. Accounting of Disclosures. All of our patients have the right to request an
“accounting of disclosures,” which is a list of certain non-routine
disclosures our practice has made of your PHI. To receive an accounting
of disclosures, contact the Privacy Officer at (615) 250-6727. All requests
for an “accounting of disclosures” must state a time period, which may not
be longer than six (6) years from the date of disclosure and may not
include dates before April 14, 2003. The first list you request within a 12-
month period is free of charge, but we may charge you for additional lists
within the same 12-month period. We will notify you of the costs involved
with additional requests, and you may withdraw your request before you
incur any costs.

6. Right to a Paper Copy of This Notice. You are entitled to receive a paper
copy of our Notice of Privacy Practices. You may ask us to give you a
copy of this notice at any time. To obtain a paper copy of this notice,
contact the Privacy Officer at (615) 250-6727.

7. Right to File a Complaint. 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. To file a complaint,
contact the Privacy Officer at (615) 250-6727. You will not be penalized
for filing a complaint.

8. Right to Provide an Authorization for Other Uses and Disclosures. We will
obtain your written authorization for uses and disclosures that are not
identified by this notice or permitted by applicable law. We will not use,
disclose, or otherwise sell your PHI for marketing purposes without your
written authorization. Any authorization you provide to us regarding the
use and disclosure of your PHI may be revoked at any time in writing.
After you revoke your authorization, we will no longer use or disclose your
PHI for the reasons described in the authorization. Please submit your
revocation at the same location where you submitted your original
authorization.

9. Right to Notification of a Security Breach. We are obligated to notify you in
the event that we experience a security breach, such as a computer
system hack, that results in an unauthorized disclosure of your PHI. This
obligation also extends to any business associates with whom we contract,
such as a third-party billing provider, that may experience a security
breach that results in an unauthorized disclosure of your PHI.

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