DERMATOLOGY ASSOCIATES OF ROCHESTER, P.C.

PRIVACY NOTICE

THIS NOTICE DESCRIBES HOW YOUR MEDICAL INFORMATION

MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO

THAT INFORMATION.

PLEASE REVIEW THIS NOTICE CAREFULLY.

Dermatology Associates of Rochester is committed to maintaining the privacy of your protected health information ("PHI"), which includes information about your medical condition and the care and treatment you receive from us. This Notice details how your PHI may be used and disclosed to third parties to carry out your treatment, payment for your treatment, health care operations of the practice, and for other purposes permitted or required by law. This Notice also details your rights regarding your PHI.

USE OR DISCLOSURE OF PHI

Dermatology Associates may use and/or disclose your PHI for treatment, payment for your treatment, and health care operations of the practice. The following are examples of the types of uses and/or disclosures of your PHI that may occur. These examples are not meant to include all possible types of use and/or disclosure.

Treatment – In order to provide, coordinate and manage your health care, Dermatology Associates will provide your PHI to those health care professionals, whether on our staff or not, directly involved in your care so that they may understand your medical condition and needs and possibly provide advice or treatment ( e.g., a specialist or laboratory). For example, a physician treating you for a condition such as arthritis may need to know what medications have been prescribed for you by the providers in this practice.

Payment – In order to get paid for services provided to you, Dermatology Associates will provide your PHI, directly or through a billing service, to appropriate third party payors, pursuant to their billing and payment requirements. For example, the practice may need to provide your health insurance carrier or, if you are over 62, the Medicare program with information about health care services that you received from us so that the practice can be properly reimbursed. The practice may also need to tell your insurance plan about the need to hospitalize you so that the insurance plan can determine whether or not it will pay for the expense

Health Care Operations – In order for Dermatology Associates to operate in accordance with applicable law and insurance requirements and in order for the practice to continue to provide quality and efficient care, it may be necessary for us to compile, use and/or disclose your PHI. For example, the practice may use your PHI in order to evaluate the performance of our personnel in providing care to you.

AUTHORIZATION NOT REQUIRED

Dermatology Associates may use and/or disclose your PHI, without a written authorization from you, in the following instances:

De-identified Information – Your PHI is altered so that it does not identify you and, even without your name, cannot be used to identify you.

Business Associate – To a business associate, which is someone who the practice contracts with to provide a service necessary for your treatment, payment for your treatment and health care operations ( e.g., billing service or transcription service). Dermatology Associates will obtain satisfactory written assurance, in accordance with applicable law, that the business associate will appropriately safeguard your PHI.

Personal Representative – To a person who, under applicable law, has the authority to represent you in making decisions related to your health care.

Public Health Activities - Such activities include, for example, information collected by a public health authority, as authorized by law, to prevent or control disease, injury or disability. This includes reports of child abuse or neglect.

Federal Drug Administration. - If required by the Food and Drug Administration to report adverse events, product defects or problems or biological product deviations, or to track products, or to enable product recalls, repairs or replacements, or to conduct post marketing surveillance.

Abuse, Neglect or Domestic Violence - To a government authority if Dermatology Associates is required by law to make such disclosure. If the practice is authorized by law to make such a disclosure, it will do so if it believes that the disclosure is necessary to prevent serious harm or if the healthcare provider believes that you have been the victim of abuse, neglect or domestic violence. Any such disclosure will be made in accordance with the requirements of law, which may also involve notice to you of the disclosure.

Health Oversight Activities - Such activities, which must be required by law, involve government agencies involved in oversight activities that relate to the health care system, government benefit programs, government regulatory programs and civil rights law. Those activities include, for example, criminal investigations, audits, disciplinary actions, or general oversight activities relating to the community's health care system.

Judicial and Administrative Proceeding - For example, Dermatology Associates may be required to disclose your PHI in response to a court order or a lawfully issued subpoena.

Law Enforcement Purposes - In certain instances, your PHI may have to be disclosed to a law enforcement official for law enforcement purposes. Law enforcement purposes include: (1) complying with a legal process ( i.e., subpoena) or as required by law; (2) information for identification and location purposes ( e.g., suspect or missing person); (3) information regarding a person who is or is suspected to be a crime victim; (4) in situations where the death of an individual may have resulted from criminal conduct; (5) in the event of a crime occurring on the premises of the practice; and (6) a medical emergency (not on the practice’s premises) has occurred, and it appears that a crime has occurred.

Coroner or Medical Examiner – Dermatology Associates may disclose your PHI to a coroner or medical examiner for the purpose of identifying you or determining your cause of death, or to a funeral director as permitted by law and as necessary to carry out its duties.

Organ, Eye or Tissue Donation - If you are an organ donor, Dermatology Associates may disclose your PHI to the entity to whom you have agreed to donate your organs.

Research– When Dermatology Associates is involved in research activities, your PHI may be used, but such use is subject to numerous governmental requirements intended to protect the privacy of your PHI such as approval of the research by an institutional review board and the requirement that protocols must be followed.

Avert a Threat to Health or Safety – Dermatology Associates may disclose your PHI if it believes that such disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public and the disclosure is to an individual who is reasonably able to prevent or lessen the threat.

Specialized Government Functions - When the appropriate conditions apply, Dermatology Associates may use PHI of individuals who are Armed Forces personnel: (1) for activities deemed necessary by appropriate military command authorities; (2) for the purpose of a determination by the Department of Veteran Affairs of eligibility for benefits; or (3) to a foreign military authority if you are a member of that foreign military service. The practice may also disclose your PHI to authorized federal officials for conducting national security and intelligence activities including the provision of protective services to the President or others legally authorized.

Inmates . Dermatology Associates may disclose your PHI to a correctional institution or a law enforcement official if you are an inmate of that correctional facility and your PHI is necessary to provide care and treatment to you or is necessary for the health and safety of other individuals or inmates.

Workers' Compensation - If you are involved in a Workers' Compensation claim, Dermatology Associates may be required to disclose your PHI to an individual or entity that is part of the Workers' Compensation system.

Required by Law . If otherwise required by law, but such use or disclosure will be made in compliance with the law and limited to the requirements of the law.

AUTHORIZATION

Uses and/or disclosures, other than those described above, will be made only with your written Authorization.

SIGN-IN-SHEET

Dermatology Associates may use a sign-in-sheet at the registration desk. Personnel may also use your name upon check-in call your name in the waiting room when your physician is ready to see you.

APPOINTMENT REMINDER

Dermatology Associates may, from time to time, contact you to provide appointment reminders.

TREATMENT ALTERNATIVES / BENEFITS

Dermatology Associates may, from time to time, contact you about treatment alternatives, or other health benefits or services that may be of interest to you.

MARKETING

Dermatology Associates may only use and/or disclose your PHI for marketing activities if we obtain from you a prior written Authorization. "Marketing" activities include communications to you that encourage you to purchase or use a product or service, and the communication is not made for your care or treatment. However, marketing does not include, for example, sending you a newsletter about this practice. Marketing also includes the receipt by the practice of remuneration, directly or indirectly, from a third party whose product or service is being marketed. The practice will inform you if it engages in marketing and will obtain your prior Authorization.

FUND RAISING

Dermatology Associates may use and/or disclose your demographic information and the dates that you received treatment from your physician, as necessary, in order to contact you for fund raising activities supported by the practice. If you do not want to receive these materials, please contact the Practice’s Privacy Officer to request that these fund-raising materials not be sent to you.

ON-CALL-COVERAGE

In order to provide on-call coverage for you, Dermatology Associates has established relationships with other physicians who will take your call if a physician from the practice is not available. Those on-call physicians will provide the practice with whatever PHI that they create and will, by agreement, keep your PHI confidential.

FAMILY/FRIENDS

Dermatology Associates may disclose to your family member, other relative, a close personal friend, or any other person identified by you, your PHI directly relevant to such person's involvement with your care or the payment for your care. The practice may also use or disclose your PHI to notify or assist in the notification (including identifying or locating) a family member, a personal representative, or another person responsible for your care, of your location, general condition or death. However, in both cases, the following conditions will apply:

If you are present at or prior to the use or disclosure of your PHI, the practice may use or disclose your PHI if you agree, or if the practice provides you with opportunity to object and you do not object, or if the practice can reasonably infer from the circumstances, based on the exercise of its professional judgment, that you do not object to the use or disclosure.

If you are not present, the practice will, in the exercise of professional judgment, determine whether the use or disclosure is in your best interests and, if so, disclose only the PHI that is directly relevant to the person's involvement with your care.

FACILITY DIRECTORY [see Regs § 164.510(a)]

YOUR RIGHTS

You have the right to:

Revoke any Authorization, in writing, at any time. To request a revocation, you must submit a written request to the Practice's Privacy Officer.

Request restrictions on certain use and/or disclosure of your PHI as provided by law. However, Dermatology Associates is not obligated to agree to any requested restrictions. To request restrictions, you must submit a written request to the Practice's Privacy Officer. In your written request, you must inform the practice of what information you want to limit, whether you want to limit the practice's use or disclosure, or both, and to whom you want the limits to apply. If the practice agrees to your request, we will comply with your request unless the information is needed in order to provide you with emergency treatment.

Receive confidential communications or PHI by alternative means or at alternative locations (for example at your business instead of home address). You must make your request in writing to the Practice's Privacy Officer. Dermatology Associates will accommodate all reasonable requests.

Inspect and copy your PHI as provided by law. To inspect and copy your PHI, you must submit a written request to the Practice's Privacy Officer. Dermatology Associates can charge you a fee for the cost of copying, mailing or other supplies associated with your request. In certain situations that are defined by law, the practice may deny your request, but you will have the right to have the denial reviewed as set forth more fully in the written denial notice.

Amend your PHI as provided by law. To request an amendment, you must submit a written request to the Practice's Privacy Officer. You must provide a reason that supports your request. Dermatology Associates may deny your request if it is not in writing, if you do not provide a reason in support of your request, if the information to be amended was not created by the practice (unless the individual or entity that created the information is no longer available), if the information is not part of your PHI maintained by the practice, if the information is not part of the information you would be permitted to inspect and copy, and/or if the information is accurate and complete. If you disagree with the practice's denial, you will have the right to submit a written statement of disagreement.

Receive an accounting of disclosures of your PHI as provided by law. To request an accounting, you must submit a written request to the Practice's Privacy Officer. The request must state a time period which may not be longer than six (6) years and may not include dates before April 14, 2003. The request should indicate in what form you want the list (such as a paper or electronic copy). The first list you request within a twelve (12) month period will be free, but the Practice may charge you for the cost of providing additional lists. Dermatology Associates will notify you of the costs involved and you can decide to withdraw or modify your request before any costs are incurred.

Receive a paper copy of this Privacy Notice from Dermatology Associates upon request to the Practice's Privacy Officer.

Complain to Dermatology Associates or to the Secretary of Health and Human Services if you believe your privacy rights have been violated. To file a complaint with the practice, you must contact the Practice's Privacy Officer. All complaints must be in writing.

To obtain more information on, or have your questions about your rights answered, you may contact the Practice's Privacy Officer, at (585)272-0700 or via email at info@cosmeticenhancementcenter.com.

PRACTICE'S REQUIREMENTS

Dermatology Associates of Rochester:

Is required by law to maintain the privacy of your PHI and to provide you with this Privacy Notice of the Practice's legal duties and privacy practices with respect to your PHI.

Is required to abide by the terms of this Privacy Notice.

Reserves the right to change the terms of this Privacy Notice and to make the new Privacy Notice provisions effective for all of your PHI that it maintains.

Will not retaliate against you for making a complaint.

Must make a good faith effort to obtain from you an acknowledgement of receipt of this Notice.

EFFECTIVE DATE

This Notice is in effect as of ___/___/___.

ACKNOWLEDGEMENT

I acknowledge that I have received a copy of this Notice.

_________________________________ ___________________________________
Name of Individual (Printed) Signature of Individual

___________________________________ ___________________________________

Signature of Personal Representative Relationship ( e.g., Attorney-In-Fact, Guardian, Parent if a minor)