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 READ IT CAREFULLY.

Cullman Dermatology Clinic, P.C., is required by federal law (HIPAA) to maintain the privacy of your individually identifiable health information and to provide you with notice of our legal duties and privacy practices. We will not use, release or disclose your health information except as specifically described in this Notice of Privacy Practices, unless specifically authorized by you in writing. In providing professional medical services to you, we will create, maintain and store your protected health information. This Privacy Notice applies to protected health information included as a part of your medical records generated by the P.C.

The following categories describe the ways that we may use, release, and disclose your health information for treatment, payment, and health care operations, without the need for an additional and specific signed authorization from you.

Treatment: We will use your protected health information in the provision and coordination of your health care. For example, we may disclose information to other health care providers who have a legitimate need for such information.

Payment: We may release protected health information for the purposes of determining coverage, billing, claims management, collection activities, and other reimbursement issues. For example, we may disclose treatment information when billing an insurance plan for your medical services.

Healthcare Operations: We may use and disclose your protected health information during routine healthcare operations. These operations may include quality assurance, utilization review, medical review, internal auditing, management and administration of the P.C., and educational purposes.

Unless otherwise requested, we may use or disclose health information to a family member, friend, or other personal representative to the extent necessary to help with your healthcare or with payment for your healthcare. In addition, we may use your confidential information to communicate via mail and/or to leave phone messages at home or work. We may also disclose your information when required by law. Any other uses and disclosures will be made only with your written authorization.

You have the following rights concerning your medical information, which you can exercise by presenting a written request to our Privacy Officer at the address listed below.

1. The right to request confidential communications about your health and related issues. The P.C. will accommodate all reasonable requests.

2. The right to inspect and copy your protected health information.

3. The right to amend your medical record information if you believe it to be incorrect, inaccurate or incomplete, as long as the information is created by, kept and maintained by or for our medical practice.

4. The right to obtain a statement or an 'accounting' of the P.C.'s use or disclosure of your protected health information.

5. The right to request restrictions on certain uses and disclosures of medical information. We are, however, not required to agree to your restrictions; however, if we do agree, we are bound by our agreement except when otherwise required by law or when the information is necessary to treat you.

6. The right to obtain a copy of this notice from us upon request.

To exercise any of the privacy rights described above, you must complete a written request and send it to Privacy Officer, Cullman Dermatology Clinic, P.C., 1205 County Road 1466, Cullman, AL 35058.

If you believe your privacy rights have been violated, you may file a complaint with the P.C. at the address above or with the Department of Health and Human Services, Office of Civil Rights. We will not retaliate against you for filing a complaint.

For more information about our privacy practices, please contact the Privacy Officer at the above address.

Effective Date: April 14, 2003