Please click the link below to view our new patient forms. We request that all new patients, or current patients who have not been seen within 3 years, print and fill out these forms and bring them with you along with photo identification plus the most current insurance card to your appointment.  Our Notice of Privacy Practices can be found below.  Please read this notice before completing and signing the Privacy acknowledgement located in the new patient forms.

 

New Patient Forms

Medical History Form

Privacy Policy Form

Consent for Treatment Form

Demographics and Consent Form


 

DERMATOLOGY ASSOCIATES OF SOUTH JERSEY, LLC – NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT OUR PATIENTS MAY BE USED AND DISCLOSED AND HOW THEY CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

The Health Insurance Portability & Accountability Act of 1996 (HIPAA) is a Federal program that requests that all medical records and other individually identifiable health information used or disclosed by us in any form, whether electronically, on paper or orally are kept properly confidential. This Act gives you, the patient, the right to understand and control how your Protected Health Information (PHI) is used.

Purpose of this Notice: Dermatology Associates of South Jersey is required by law to maintain the privacy of certain confidential health care information, known as Protected Health Information (PHI), and to provide you with a notice of our legal duties and privacy practices with respect to patients’ PHI. This Notice describes legal rights, advises of our privacy practices and outlines how Dermatology Associates of South Jersey is permitted to use and disclose PHI about our patients.

Dermatology Associates of South Jersey is also required to abide by the terms of the version of this Notice currently in effect. In most situations we may use this information as described in this Notice without permission, but there are some situations where we may use it only after we obtain our patients written authorization, if we are required by law to do so.

Uses and Disclosures of PHI: Dermatology Associates of South Jersey may use PHI for the purposes of payment and health care operations, in most cases without written permission. Examples of our use of PHI:

For treatment: This includes the provision, coordination, or management of health care and related services by one or more health care providers, including the coordination or management of health care by a health care provider with a third party; consultation between health care providers relating to a patient; or the referral of a patient for health care from one health care provider to another.

For payment: This includes any activities we must undertake in order to get reimbursed for the services provided to our patients, including such things as organizing PHI and submitting bills to insurance companies (either directly or through a third party), management of billed claims for services rendered, medical necessity determinations and reviews, utilization review and collection of outstanding accounts.

Dermatology Associates of South Jersey will not use or disclose more information for payment purposes than is necessary. This is known as using only the minimum necessary amount to accomplish the purpose of use or disclosure. We are accountable to the Secretary of Health and Human Services to safeguard (keep secure) and protect (keep private) our patients’ information.

For health care operations: This includes quality assurance activities, licensing and training programs to ensure that our personnel meet our standards of care and follow established policies and procedures, auditing functions, cost management analysis, processing grievances and complaints, and customer service.

Dermatology Associates of South Jersey may also be required or permitted to disclose your PHI for long force and other legitimate reasons. In all situations, we shall do our best to assure its continued confidentiality to the extent possible.

We may contact you, by phone or in writing, to provide appointment reminders.

Notification in the Case of a Breach: Dermatology Associates of South Jersey is required by law to notify our patients in case of a breach of their unsecured protected health information when it has been or is reasonably believed to have been accessed, acquired or disclosed as a result of a breach.

Use and Disclosure of PHI Without Your Authorization: Dermatology Associates of South Jersey is permitted to use PHI without written authorization, or opportunity to object in certain situations, including:

  1. For Dermatology Associates of South Jersey’s use in obtaining payment for services provided or in other health care operations;
  2. To another health care provider or entity for the payment activities of the provider or entity that receives the information (such as your hospital or insurance company);
  3. To another health care provider (such as the hospital) for the health care operations activities of the entity that receives the information as long as the entity receiving the information has or has had a relationship with our patients and the PHI pertains to that relationship;
  4. For health care fraud and abuse detection or for activities related to compliance with the law;
  5. To a family member, other relative or close personal friend or other individual involved in our patients care if we obtain verbal agreement to do so or if we give our patients an opportunity to object to such a disclosure and you do not raise an objection. We may also disclose health information to family, relatives or friends if we infer from the circumstances that there is no objection. For example, we may assume our patients agree to our disclosure of personal health information to their spouse or parent when their spouse or parent has called us for them. In situations where our patients are not capable of objecting (because the patients are not present or due to incapacity or medical emergency), we may, in our professional judgment, determine that a disclosure to our patient’s family member, relative or friend is in the best interest. In that situation, we will disclose only health information relevant to that person’s involvement in our patient care;
  1. To a public health authority in certain situations (such as reporting a birth, death or disease as required by law, as part of a public health investigation, to report child or adult abuse or neglect or domestic violence, to report adverse events such as product defects or to notify a person about exposure to a possible communicable disease) as required by law;
  2. For health oversight activities including audits or government investigations, inspections, disciplinary proceedings and other administrative or judicial actions undertaken by the government (or their contractors) by law to oversee the health care system;
  3. For judicial and administrative proceedings as required by a court or administrative order, or in some cases in response to a subpoena or other legal process;
  4. For law enforcement activities in limited situations, such as when there is a warrant for the request or when the information is needed to locate a suspect or stop a crime;
  5. For military, national defense and security and other special government functions;
  6. To avert a serious threat to the health and safety of a person or the public at large;
  7. For workers’ compensation purposes and in compliance with workers’ compensation laws;
  8. To coroners, medical examiners and funeral directors for identifying a deceased person, determining cause of death, or carrying on their duties as authorized by law; and
  9. If our patient is an organ donor, we may release health information to organizations that handle organ procurement or organ, eye or tissue transplantation or to an organ donation bank, as necessary, to facilitate organ donation and transplantation;
  10. Any phone numbers and corresponding voice mail systems provided to our office can and will be used for contact including but not limited to: appointment reminders, changes in scheduling, obtaining additional personal or insurance information and results from any laboratory or pathology testing.

Any other use or disclosure of PHI, other than those listed above, will only be made with written authorization (the authorization must specifically identify the information we seek to use or disclose, as well as when and how we seek to use or disclose it). Authorization may be revoked at any time, in writing, except to the extent that we have already used or disclosed medical information in reliance on that authorization.

Patient Rights: Our patients have a number of rights with respect to the protection of their PHI. Dermatology Associates of South Jersey will permit individuals to exercise patient rights.

The right to access, copy or inspect PHI. This means our patients may come to our offices and inspect and copy most of the medical information about them that we maintain in both paper and electronic format. We will generally permit access, copying or inspection of PHI. Information held electronically must be provided in electronic form if requested by the patient.

The right to amend PHI. Our patients have the right to ask us to amend their written medical information.
The right to request an accounting of our use and disclosure of an individual’s PHI. Our patients may request an accounting from us of

certain disclosures of their medical information that we have made in the last six years prior to the date of the request.

We are not required to give an accounting of information we have used or disclosed for purposes of treatment, payment or health care operations.

We also are not required to give an accounting of our uses of PHI for which we already have a written authorization for such use. To request an accounting of the medical information that we have used or disclosed that is not exempted from the accounting requirement, contact the Privacy Officer listed at the end of this Notice.

The right to request that we restrict the uses and disclosures of an individual’s PHI. Our patients have the right to request that we restrict how we use and disclose their medical information that we have for treatment, payment or health care operations, or to restrict the information that is provided to family, friends and other individuals involved in their health care. But if the information is needed to provide emergency treatment, then we may use the PHI or disclose the PHI to a health care provider to provide them with emergency treatment.

Our patients have a right to a restriction to disclosure of PHI to a health plan for payment if the patient has paid out of pocket in full for the services and items provided in that visit.

Revisions to the Notice: Dermatology Associates of South Jersey reserves the right to change the terms of this Notice at any time, and the changes will be effective immediately and will apply to PHI that we maintain. Any material changes to the Notice will be promptly posted in our facilities and posted to our website, if we maintain one. Our patients will be given access to, and a copy at their request, the latest version of this Notice at their next visit or by contacting the Privacy Officer. 150 Century Parkway, Suite C., Mount Laurel, NJ 08054. 856-206-0201

Your Legal Rights and Complaints: Our patients also have the right to complain to us, or to the Secretary of the United States Department of Health and Human Services, if they believe their privacy or security rights have been violated. Complainants will not be retaliated against in any way for filing a complaint with us or to the government. Should our patients have any questions, comments or complaints they may direct all inquiries to the Privacy Officer. Individuals will not be retaliated against for filing a complaint.

To complain to the Secretary of Health and Human Services please use the following information and address: Suite 436, Public Ledger Bldg, 150 S. Independence Mall West, Phila 19106

Effective Date of the Notice: October 25, 2019

 

×

Make an appointment and we’ll contact you.