Privacy & Health Information Practices

image Dermatology originates and maintains paper and/or electronic records describing a patient's health history, symptoms, examination and test results, diagnoses, treatment, and any plans for future care or treatment of patients.

Patients understand that this information serves as:

·           A basis for planning care and treatment,

·           A means of communication among the many health professionals who contribute to care,

·           A means by which a third-party payer can verify that services billed were actually provided, and

·           A tool for routine healthcare operations such as assessing quality and reviewing the competence of healthcare professionals.

Patients understand and have been provided with a "Notice of Information Practices" that provides a more complete description of information uses and disclosures, understanding that they have the following rights and privileges:

·           The right to review the Notice prior to signing their consent,

·           The right to object to the use of health information for directory purposes, and

·           The right to request restrictions as to how health information may be used or disclosed to carry out treatment, payment, or health care operations.

Patients understand that image Dermatology is not required to agree to the restrictions requested. Patients understand that they may revoke this consent in writing, except to the extent that the organization has already taken action in reliance thereon. Patients also understand that by refusing to sign the image Dermatology consent forms or revoking the consent, this organization may refuse to treat them as permitted by Section 164.506 of the Code of Federal Regulations. 

Patients further understand that image Dermatology reserves the right to change its Notice and practices prior to implementation, in accordance with Section 164.520 of the Code of Federal Regulations. Should image Dermatology change its Notice, it will provide or send a copy of any revised notice to the address provided by the patient (whether U.S. mail or, if agreed, email).

Patients understand that as part of image Dermatology's treatment, payment, or billing or health care operations, as provided for in the Notice, it may become necessary to disclose protected health information to another entity, and patients consent to such disclosures for these permitted uses, including disclosures via fax.

Jeanine B. Downie, M.D.
Diplomate of American Board of Dermatology
image Dermatology P .C.
51 Park Street
Montclair, NJ 07042
973.509.6900
Fax: 973.509.6939