Notice of Privacy Practices

Modern Dermatology Atlanta, a Limited Liability Company (“MDA”)

Privacy Practice Questions/Concerns: 770-250-7199

Effective Date: March 1, 2018

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.

Your privacy is important to us and we are committed to maintaining the confidentiality of your medical information. We are required by law to provide you with this notice that explains our privacy practices with regard to your medical information and how we may use and disclose your protected health information for treatment, payment, and for health care operations, as well as for other purposes that are permitted or required by law. We have described in this notice your rights regarding the privacy of your protected health information and our legal obligations with respect to your medical information.

Table of Contents 

  1. How MDA May Use or Disclose your Health Information
  2. When MDA May Not Use or Disclose Your Health Information
  3. Your Health Information Rights
  4. Changes to this “Notice of Privacy Practices”
  5. Complaints 
  1. How MDA May Use or Disclose Your Health Information 
  1. Treatment: We will use and disclose your protected health information to provide and manage your health care and any related services. We will also disclose your health information to other physicians and healthcare providers who are also treating you or can provide you services that we do not. One example would be to disclose your health information to a specialist to whom we have referred you for a diagnosis and/or treatment. Another example would be to share your information with a pharmacist who needs it to dispense a prescription or to a laboratory that needs it to perform a test.
  2. Signing in: We may use and disclose medical information about you during the sign in process when you arrive in the office and when we call out your name to see you for your visit.
  3. Payment: We use and disclose medical information about you to obtain payment for the services we provide. One example would be to include information, such as your identification, your diagnosis, the procedures performed, and supplies used to render your services, to the third party payer. Per our policy, we require a credit card on file for individuals who do not pay their service charges at the time of the visit. To enact this policy we disclose your name and credit card information to our merchant services provider, Square. All credit card information is stored securely in a Payment Card Industry compliant manner.
  4. Health Care Operations: We will use and disclose your protected health information to support the business activities or our practice. One example would be to use medical information about you to review and evaluate our treatment and services or to evaluate the performance of the care our staff provides you. Another example would be to disclose your health information to a third party business associate who bills, consults, or transcribes services for our practice.
  5. Appointment reminders: We will use and disclose your protected health information to contact you as a reminder about scheduled appointments and treatments
  6. Treatment alternatives: We will use and disclose your protected health information to obtain possible treatment alternatives that are of interest to you. We may contact you to provide information about products and services related to your treatment, case management or care coordination
  7. Others Involved in Your Care: To the extent applicable by law we may also disclose medical information to members of your family or others who you identify as individuals that can help you when you are sick, injured, or after your death.
  8. Coroners, Medical Examiners, and Funeral Directors: We may disclose health information to a coroner or medical examiner if deemed necessary to determine the cause of death. We may disclose of your health information to funeral directors as necessary to carry out their duties.
  9. Judicial and Administrative Proceedings: We may use and disclose your health information if ordered to do so by a court or administrative tribunal that is handling a lawsuit or other dispute. We may also use and disclose your health your health information in response to a subpoena, discover request, or other lawful process, but only if reasonable efforts have been made to notify you of the request or to protect the health information requested.
  10. To Avert a Serious Threat to Public or Safety: We will use and disclose your protected health information to a public health authority for purposes related to preventing or controlling disease, injury, or disability; reporting child or dependent adult abuse or neglect; reporting domestic violence; reporting to the Food and Drug Administration problems with products and reactions to medications; and reporting disease or infection exposure. When we report suspected dependent adult abuse or domestic violence, we will inform you or your personal representative unless we believe, in our professional judgement, that such notification would place you at risk of serious harm.
  11. Workers’ Compensation: We will use and disclose your protected health information for workers’ compensation or similar programs that provide benefits for work related injuries or illness.
  12. Research: Under certain circumstances we may use or disclose your health information for research. In most cases, we will ask for your written authorization before doing so. Sometimes, we may use or disclose your health information for research without your written authorization. In those cases, the use or disclosure of your information would have to be approved by an Institutional Review Board or Privacy Board.
  13. Health Oversight Activities: To the extent permitted and/or required by law we may use and disclose your health information to health oversight agencies during the course of audits, investigations, inspections, licensure, and other proceedings.
  14. Inmates: If you are an inmate, we may disclose your health information to the law enforcement official or correctional institution having custody to provide you with health care, and to protect your health or safety or that of other inmates or persons involved in supervising or transporting inmates.
  15. Military and Veterans: We may use and disclose the health information of Armed Forces personnel to appropriate military command authorities for the execution of their military mission. We may also use and disclose health information about foreign military personnel to foreign military authorities.
  16. As Required by Law: we will use and disclose your protected health information when permitted and/or required by the federal state, or local law. You will be notified of such disclosures. 
  1. When MDA May Not Use or Disclose Your Health Information 

MDA will not use or disclose any health information that identifies you without your written consent except as described in section A of this Notice of Privacy Practices. If you do authorize MDA to use or disclose your health information for another purpose you may revoke your authorization at any time. Disclosures made from a prior authorization are not affected by subsequent revocation. 

  1. Your Health Information Rights 

Your health record is the physical property of the health care provider or facility that compiled it, however, the information belongs to you. A summary of your rights is designated below: 

  1. Right to a paper copy of this Privacy Notice: You can print a copy directly from our website moderndermatl.com (select “Privacy Notice” at bottom of main page). Alternately, you can call or email us and request we print and mail a copy to your preferred address.
  2. Right to Inspect and Copy your Health Record: You have a right to inspect a copy of the protected health information that we maintain about you in our health record for as long as we maintain that information. This health record includes your medical, billing, and any other records that we use to make decisions about you. We may charge you a fee for the costs associated with fulfilling your request (e.g., copying, billing, etc.) but will notify you of the costs before they are incurred.
    1. Psychotherapy notes that may be included our records about you are not available for your inspection or copying by law.
    2. To inspect or obtain a copy of your medical information you must submit your request in writing to the attention of “Medical Records” to Modern Dermatology Atlanta LLC, 120 Stonebridge Pkwy, Ste 440, Woodstock, GA 30189. You may mail or physically deliver the request to our office. We will have 30 days to respond to your request for information that is maintained in our office database. If the information is stored at a remote site we are allowed up to 60 days provided we inform you of this delay.
  3. Right to Request an Amendment: You have a right to request that we amend your health information if you believe it is incorrect or incomplete. You must make a request to amend in writing and include the reasons you believe the information is inaccurate or incomplete. We are permitted to deny your request if it is not in writing or does not include a reason to support the request. Additionally, we may deny a request if the information was not created by us or if the person who created it is no longer available to make the amendment; the information is not part of the record which you are permitted to inspect and copy; the information is not part of the designated health record kept by our practice; or if it is the opinion of the health care provider that the information is accurate and complete. If we deny your request, you may submit a written statement of your disagreement with the decision and we may, in turn, write a rebuttal. All information related to any request to amend will be maintained and disclosed in conjunction with any subsequent disclosure of the disputed information.
  4. Right to Request Restrictions: You can request a restriction or limitation of how we use or disclose your medical information for treatment, payment, or health care operations. Your request must be made in writing to our practice.
  5. Right to an Accounting of Disclosures: You can receive an accounting of disclosures of your health information made by MDA to those outside of our practice with the exception of disclosures made for Treatment, Payment, Health Care Operations (see A1, A3, A4 above). Your request must be made in writing and must state the time period for the requested information. You may not request information for a period of time greater than 6 years (minimum length of time we are legally required to maintain your records).
  6. Right to Request Confidential Communications: You can request how we communicate with you to preserve your privacy. One example would include a request to call you only at a particular phone number or at a specific mailing address. Your request must be in writing and must clearly specify how we are to contact you. We will accommodate all reasonable requests. 
  1. Changes to this “Notice of Privacy Practices:’ We reserve the right to amend this Notice of Privacy Practices at any time. Until such amendment is made we are required by law to comply with the terms of this notice currently in effect. After an amendment is made, the revised Notice of Privacy Practices will apply to all protected health information that we maintain, regardless of when it was created or received. A copy of the current notice can be found posted in our reception area, on our website (see bottom of the main scroll page), and will be available for print at each of your appointments. 
  1. Complaints: If you believe we have violated your medical information privacy rights you have the right to file a complaint directly with our practice or the Secretary of Health and Human Services. Please know there would be no retaliation for filing your complaint.
  2. To file a complaint with our practice you must make it in writing within 180 days of the suspected violation. Provide as much detail as you are able about the suspected violation and send or deliver it to the attention of “Privacy Officer” to Modern Dermatology Atlanta LLC, 120 Stonebridge Pkwy, Ste 440, Woodstock, GA, 30189.