Dermatology & Advanced Skin Care, Inc.

6021 University Blvd, Suite 390, Ellicott City, MD 21043

PATIENT CONSENT FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION

Dermatology & Advanced Skin Care may use and disclose protected health information (PHI) about me to carry out treatment, payment and healthcare operations (TPO). I have the right to review the Notice of Privacy Practices prior to signing this consent. Dermatology & Advanced Skin Care reserves the right to revise its Notice of Privacy Practices at any time. A revised Notice of Privacy Practices may be obtained by forwarding a written request to our Privacy Officer at the above address.

CONSENT TO BE CONTACTED BY DERMATOLOGY & ADVANCED SKIN CARE

Dermatology & Advanced Skin Care contacts patients regarding such matters as appointment reminders, insurance items and issues pertaining to clinical care, including laboratory results. Please indicate your where we can contact you and if we can leave a message

Check box if we can contact you here / Check box if we can leave message on answering machine / Check box if we can leave message with person answering phone / Check box if we can contact you about cosmetic procedures
HOME
CELL
WORK
E-MAIL

Check the locations we can send mail:

__ Mail to my home__ E-mail address ______

__E-mail monthly specials to the email address above.

AUTHORIZATION TO RELEASE PROTECTED HEALTH INFORMATION

I authorize Dermatology & Advanced Skin Care to disclose

__ Appointment Information__Information about Cosmetic Procedures

__ Medical Information/Records __ Financial Information

To:

Person or Entity to Receive the Information (e.g. family member)

This authorization applies to ______and expires on ______

(Specific or all dates of service) (Date or Defined Event)

I have the right to request that Dermatology & Advanced Skin Care restrict how it uses or discloses my PHI to carry out TPO. However, the practice is not required to agree to my requested restrictions, but if it does, it is bound by this agreement.

By signing this form, I am consenting to Dermatology & Advanced Skin Care’s use and disclosure of my PHI to carry out TPO. I may revoke my consent in writing to the above address except to the extent that the practice has already made disclosures in reliance upon my prior consent. If I do not sign this consent, Dermatology & Advanced Skin Care may decline to provide treatment to me.

Signature of Patient or Legal Guardian Print Name of Patient or Legal Guardian/Relationship to Patient

______

Patient’s NameDate