SOUTH HILLS DERMATOLOGY, PC INSURANCE AUTHORIZATION FORM

South Hills Dermatology, PC may leave medical information with/on the following: (Please select the appropriate choice(s) below -You may choose more than one)

_ _ Message on Answering Machine _ _ Spouse/Signlfic~infOtner.:.-Name-·

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Name ______________

Parent

- - - (Must check if patient is a minor)

_ _ Other: i.e. Son/Daughter/etc. Phone---------

Name(s) --OR-

- - None of the above. SPEAK TO ME ONLY. I authorize the release of any medical information necessary to process insurance claims and the release of information back to my physician (s). I request the payment of authorized benefits made either to me or on my behalf to South Hills Dermatology for any services furnished to me. I acknowledge that I have reviewed the posted notice of privacy practices for South Hills Dermatology, signed by either the patient or a personal representative. A personal representative is the person legally responsible for the patient.

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Srig-n-a'tu_r_e_o~f~P'a"ti~e-nV~P=-ers __o_n_a~IR=-ep_r_e_s_e-nt'a"ti~v~e----------------

Date

Print Patient's Name Date of Birth Address _____________________ City

Zip Code

State

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SS No. _______

Primary Phone #

Home ( ) Cell ( )

Work ( )

Secondary Phone #

Home ( ) Cell ( )

Work ( )

If the Patient is different from the insurance policy holder. please complete the following: Policy Holder Name

Date of B i r t h - - - - - - - -

SS# *

Relationship to Patient------------*

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*

*

*

*

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If applicable, Secondary Insurance Information: Policy Holder Name Relationship to P a t i e n t - - - - - - - - - - -

Date of Birth - - - - - - - -

SOUTH HILLS DERMATOLOGY, PC

AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION

Patient Name Add~ss

Date of Birth - - - - - - - - - -

_____________________________________________________

I hereby authorize Dr. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - to release copies of the following portions of my medical record: _ Complete Medical Records- in~l~c.ii!lg all progress notes, pathology and lab reports.

Other-·-----------~------These copies are to be released and sent/faxed to: _South Hills Dermatology, PC 363 Vanadium Road Pittsburgh, PA 15243 Fax: 412-279-6722

- -_ -_ --_ -_ -_ -Fax: Other: L_j, ___-_ _ Address:

This information is protected by state and federal laws. This authorization shall be valid for the next six months. I understand that this consent may be revoked in writing at any time. Pennsylvania law prohibits South Hills Dermatology, PC from making any further disclosure of this. information unless further disclosure is expressly permitted by written consent. A general authorization for the release of medical or other information is not sufficient for this purpose. Date _ _ _ _ _ __

· Patient's Signature X

Witness's/Staff Person's Signature----------------- Date _ _ _ _ _ __ If the Patient is unable to consent or is a minor, complete the following: Patient is a minor(_ years of age)or is unable to provide a signature on this form. Date __________ Signature of parent, legal representative (legal guardian, executor or administrator of the estate) Relationship to P a t i e n t - - - - - - - - - - - - - - - - - - - - -

Date _ _ _ _ _ _ __

Witness S i g n a t u r e - - - - - - - - - - - - - - - - - -

Date _ _ _ _ _ _ __

Scott Township Office 363 Vanadium Road Pittsburgh, PA 15243 412-279-6799

McMurray Office 2001 Waterdam Plaza Drive McMurray, PA 15317 724-942-0992

NOTICE OF PRIVACY PRACTICES FOR SOUTH HILLS DERMATOLOGY P.C. EFFECTIVE 10/01/05 TIDS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW TO GET ACCESS TO TIDS INFORMATION. PLEASE READ IT CAREFULLY. If you have any questions regarding this notice, you may contact our privacy officer at: South Hills Dermatology, PC Attention: Privacy Officer 363 Vanadiuin Road Suite 101 Telephone No: 412-279-6799

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fax: 412-279-6722

YOUR PROTECTED HEALTH INFORMATION

South Hills Dermatology, PC is required by the federal privacy rule to maintain the privacy of your health information that is protected by the rule,. and to provide you with notice of our legal duties and privacy practices with respect to your protected health care information. We are required to abide by the terms of the notice currently in effect. Generally speaking, your protected health information is any information that relates to your past, present or future physical or mental health or condition, the provision of health care to you, or payment for health care provided to you, and individually identifies you or reasonably can be used to identify you. Your medical and billing records at our practice are examples of information that usually will be regarded as your protected health information.

ll. USES AND DISCLOSURE OF YOUR PROTECTED HEALTH INFORMATION a.

We may use and disclose your medical records only for each of the following purposes: treatment, payment or health care operations. (Not every possible use or disclosure for treatment, payment and health care operations purposes will be listed.

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1.

Treatment: Treatment means providing, coordinating, or managing

health care and related services by one or more heath care providers. Some examples follow: • We may hare and discuss your medical information with an outside physician, laboratory, radiology center or another health care facility with whom we are consulting regarding you. • We may leave messages with immediate family members or on an answering machine regarding specific information such as the attending doctor's name, the name of the medication requested to be refilled, or the date and time of your impending appointment. • We may send you a post card via the US mail to remind you of a needed follow-up appointment. • We may conduct training programs for medical students and/or other students. 2. Payment: Payment means such activities as obtaining reimbursements for services, confnming coverage, billing or collection activities, and utilization review. Some examples follow: • Sharing your demographic information with other health care providers who seek this information to obtain payment for health care services provided to you. • Providing medical records and other documentation to your health insurer to support the medical necessity of a service. . 3. Health care operations: Health care operation include the business aspects of running our practice, such as conducting quality assessment and improvement activities, auditing functions, cost management analysis, and customer service. Some examples follow: J

• · Accreditation, certifications, licensing and credentialing activities. • Health care fraud and abuse detection and compliance programs.

b.

Uses and disclosures for other purposes: We may disclose your protected health information for other purposes. This section generally describes these purposes by category. Not every use or disclosure in a category will be listed. 1. Individual involved in care or payment for care: We may disclose your protected health information to some involved in your care such as a parent, a spouse, a family member or a close friend. 2. Notification purposes: We may use and disclose your protected· health information to notify a person responsible for your care. 3. Required by law: As required by federal, state or local law, we may disclose protected health information to comply with mandatory reporting requirements. An example would be for child abuse reporting pmposes. PAGE20F4

4. Other pubic health requirements: As required by law, protected health information may be disclosed to public health or legal auth'orities for the jurisdiction of disease, injury or disability prevention or control. An example would be communicable disease reporting. 5. For the purpose of reporting abuse, neglect or domestic violence. 6. For the purpose of health oversight activities that are authorized by law: Examples include audits, inspections, and investigations such as Drug Enforcement Agency inspection of records. 7. Judicial and administrative proceedings: An example would be a response to a court order or subpoena. 8. Law enforcement purposes: An example would be to comply with legal process such as a search warrant. 9. Coroners and medical examiners: An example would be for the pwpose of identifying a deceased patient. 10. Funeral directors: Information would be provided to the extent necessary to perform their duties. 11. Organ and tissue donation. 12. Threat to public safety: An example would be the protection of a third party from harm. 13. Specialized government functions: An example would be disclosure for pwposes involving national security and/or intelligence. 14. Worker's Compensation and similar programs: Protected health information may be revealed to the extent necessary to comply with the law and your individual case. 15. Business Associates: An example would be disclosure of protected health information to our billing service. 16. Creation of a de-identified information: For example, we may use your protected health information in the process of removing those aspects, which could identify you so that the information can be disclosed to a researcher. 17. Incidental disclosure: We may disclose protected health information as a by-product of an oth.erwise permitted use or disclosure. For example, other patients may overhear your name being called in the reception area. 18. Uses and disclosures with authorization: For all other purposes . which do not fall under a category listed under sections II A and Im, we will obtain your Written authorization to use or disclose your protected health information. Your authorization can be revoked at any time except to the extent that we have relied on the authorization. PAGE3 OF4

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m PATIENT PRIVACY .RIGHTS: You have the following rights with respect to your protected health information, wbich you can exercise by presenting a written request to the privacy officer. .

A.

B.

C. D. E. F.

The right to request that we further restrict use and disclosure of your protec~ed health information for treatment, payment, or health care operations, to sonieone who is involved in your care, the payment for your care, or for notification · purposes. We are not required to agree to the request The right to reasonable requests to receive a ·confidential communication of . protected health information from us by alterna~ve ID.eaDS or at alternative locations ... The right to amend yo~ protected health information if the information is incomJ)Iete Qr incorreCt. The right to inspect and copy your protected health information. This right is subject to limitations and we may impose·a fee for labor and supplies~ The right to receive an ·accounting of disClosure of protected health information. The right_ to obtain a paper copy ofthis notice from us UpOn request. '

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IV. CHANGES TO THIS NOTICE:

We reserve the right to change this notice at any time. We further reserve the right to make any change effective fot all protected health information that we maintain at the tinie ofthe change including · information that we created or received prior to the effective date of the change~ . We will post a copy of our current notice in the reception area of the practice. At any time, patients may review the· current notice by contacting our privacy officer.

.COMPLAINTS: If you believe that we have violated your privacy rights, V. you may submit a complaint to the practice or ~e Secretary of Health and Human Services. To a complaint with the practice, submit the complaint in writing to our priv~cy officer. We Will not retaliate against you for filing a complaint. ·

file

VI. LEGAL EFFECT OF THIS NOTICE:

This notice is not intended to create contractua.I.ot other rights independent to those created in the federal privacy rule.

THANK YOU FOR READING OUR NOTICE

PLEASE INDICATE THAT YOU HAVE THIS NOTICE BY SIGNING THE "ACKNOWLEDGEMENT OF RECEIPT OF NOTICE" ON THE .INTAKE FORM · PAGE40F4