Notice of Privacy Practice Form Skin MD, LLC
I understand that under the Health Information Portability and Accountability Act (HIPAA), I have rights to privacy regarding my protected health information. I agree that I am a patient of Skin MD, LLC. I hereby acknowledge that I may request a copy of Skin MD, LLC’s Notice of Privacy Practices. The Notice of Privacy Practice provides detailed information about how the practice may use and disclose my confidential information. I understand that Skin MD, LLC has reserved a right to change their privacy practices that are described in the Notice. I also understand that a copy of any revised Notice will be provided to me or made available.
Consent to Leave Messages
I give my consent to Skin MD, LLC to leave messages regarding scheduling, treatment, surgery, results, lab or radiology, or other information as necessary on the number(s) documented in my electronic health record.
Authorization for Release of Information
I authorize Skin MD, LLC to speak with the following individuals or individuals documented in my electronic health record and give them access to my medical record, health information, scheduled appointments, test results or billing questions.
Printable Forms and Documents
Notice of Privacy Practice Form and HIPAA
Full HIPAA Notice of Privacy Practices
