At Dermio, LLC (“DERMIO”), we understand that medical information about you and your health is personal. We are committed to protecting medical information about you. We create a record of the care and services you receive directly from one of our dermatologists. We need this record to provide you with quality care and to comply with certain legal requirements. This Notice of Privacy Practices (“Notice”) applies to all of the records of your care generated by DERMIO.

This Notice will tell you about the ways in which DERMIO may use and disclose medical information about you, referred to below as protected health information (“PHI”). This Notice also describes your rights and certain obligations DERMIO has regarding the use and disclosure of PHI. This Notice describes DERMIO’s practices and that of: all DERMIO physicians and all employees, staff and other DERMIO personnel. All these persons working at different entities, sites and locations may share PHI with each other for treatment, payment or operations as described in this Notice.

HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU.

DERMIO may use or disclose your PHI for the purposes described in more detail below, without obtaining written authorization from you. In addition, DERMIO and the members of its medical and allied health professional staff who participate in the organized health care arrangement described below may share your PHI with each other as necessary to carry out their treatment, payment and health care operations related to the organized health care arrangement.

For Treatment

DERMIO may use and disclose PHI in the course of providing, coordinating, or managing your medical treatment, including the disclosure of PHI for treatment activities of another health care provider.

For Payment

DERMIO may use and disclose PHI in order to bill and collect payment for the health care services provided to you. For example, DERMIO may need to give PHI to your health plan in order to be reimbursed for the services provided to you. DERMIO may also disclose PHI to its business associates, such as billing companies, claims processing companies, and others that assist in processing health claims. DERMIO may also disclose PHI to other health care providers and health plans for the payment activities of such providers or health plans.

For Health Care Operations.

DERMIO may use and disclose PHI as part of its operations, including for quality assessment and improvement, such as evaluating the treatment and services you receive and the performance of staff and physicians in caring for you, patient surveys, provider training, underwriting activities, compliance and risk management activities, planning and development, and management and administration. DERMIO may disclose PHI to doctors, nurses, technicians, students, attorneys, consultants, accountants, and others for review and learning purposes, to help make sure DERMIO is complying with all applicable laws, and to help DERMIO continue to provide quality health care to its patients. DERMIO may also disclose PHI to other health care providers and health plans for such entity’s quality assessment and improvement activities, credentialing and peer review activities, and health care fraud and abuse detection or compliance, provided that such entity has, or has had in the past, a relationship with the patient who is the subject of the information.

As Required by Law and Law Enforcement.

DERMIO may use or disclose PHI when required to do so by applicable law and when ordered to do so in a judicial or administrative proceeding. DERMIO may also use or disclose PHI to identify or locate a suspect, fugitive, material witness, or missing person, when dealing with gunshot and other wounds, about criminal conduct, to report a crime, the location of the crime or victims, or the identity, description, or location of a person who committed a crime, or for other law enforcement purposes.

For Public Health Activities and Public Health Risks.

DERMIO may disclose PHI to government officials in charge of collecting information about births and deaths, preventing and controlling disease, or to notify a person who may have been exposed to a communicable disease or may be at risk of contracting or spreading a disease or condition.

For Health Oversight Activities.

DERMIO may disclose PHI to the government for oversight activities authorized by law, such as audits, investigations, inspections, licensure or disciplinary actions, and other proceedings, actions or activities necessary for monitoring the health care system, government programs, and compliance with civil rights laws.

Coroners, Medical Examiners, and Funeral Directors.

DERMIO may disclose PHI to coroners, medical examiners, and funeral directors for the purpose of identifying a decedent, determining a cause of death, or otherwise as necessary to enable these parties to carry out their duties consistent with applicable law.

Organ, Eye, and Tissue Donation.

DERMIO may release PHI to organ procurement organizations to facilitate organ, eye, and tissue donation and transplantation.

Research.

Under certain circumstances, DERMIO may use and disclose PHI for medical research purposes. For example, a research project may involve comparing the health and recovery of all patients who received one medication to those who received another, for the same condition.

To Avoid a Serious Threat to Health or Safety.

DERMIO may use and disclose PHI, to law enforcement personnel or other appropriate persons, to prevent or lessen a serious threat to the health or safety of a person or the public.

Specialized Government Functions.

DERMIO may use and disclose PHI of military personnel and veterans under certain circumstances. DERMIO may also disclose PHI to authorized federal officials for intelligence, counter intelligence, and other national security activities, and for the provision of protective services to the President or other authorized persons or foreign heads of state or to conduct special investigations.

Disclosures to You or for HIPAA Compliance Investigations.

DERMIO may disclose your PHI to you or to your personal representative, and is required to do so in certain circumstances described below in connection with your rights of access to your PHI and to an accounting of certain disclosures of your PHI. DERMIO must disclose your PHI to the Secretary of the United States Department of Health and Human Services (the "Secretary") when requested by the Secretary in order to investigate DERMIO's compliance with privacy regulations issued under the federal Health Insurance Portability and Accountability Act of 1996.

Patient List; Marketing.

Unless you object, DERMIO may use some of your PHI to maintain a list of patients it has served. This information may include your name, treatment facility, and the services DERMIO provided to you. This patient list and the information on it may be used for marketing purposes.

Disclosures to Individuals Involved in Your Health Care or Payment for Your Health Care.

Unless you object, DERMIO may disclose your PHI to a family member, other relative, friend, or other person you identify as involved in your health care or payment for your health care. In addition, DERMIO may disclose PHI about you to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status and location.

OTHER USES AND DISCLOSURES.

Other types of uses and disclosures of your PHI not described above will be made only with your written authorization, which with some limitations; you have the right to revoke in writing. If you revoke your permission, DERMIO will no longer use or disclose PHI about you for the reasons covered in your written authorization. You understand that DERMIO is unable to take back any disclosures already made with your permission, and that DERMIO is required to retain records of the care provided to you.

REGULATORY REQUIREMENTS.

DERMIO is required by law to maintain the privacy of your PHI, to provide individuals with notice of DERMIO’s legal duties and privacy practices with respect to PHI, and to abide by the terms described in the Notice currently in effect.

RIGHTS

You have the following rights regarding your PHI:

Restrictions:

You may request that DERMIO restrict the use and disclosure of your PHI. To request restrictions, you must make your request in writing to our Privacy Officer using the applicable DERMIO form. In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit our use, disclosure or both; and (3) to whom you want the restrictions to apply, for example, disclosures to your spouse.

Alternative Communications.

You have the right to request that communications of PHI to you from DERMIO be made by particular means or at particular locations. For instance, you might request that communications be made at your work address, instead of your home address. Your requests must be made in writing using DERMIO’s form and sent to the Privacy Officer. DERMIO will accommodate your reasonable requests.

Inspect and Copy

Generally, you have the right to inspect and copy your PHI that DERMIO maintains, provided that you make your request in writing to DERMIO’s Privacy Officer. If you request copies of your PHI, we may impose a reasonable fee to cover copying and postage. If we deny access to your PHI, we will explain the basis for denial and your opportunity to have your request and the denial reviewed by a licensed health care professional (who was not involved in the initial denial decision) designated as a reviewing official. If DERMIO does not maintain the PHI you request and if we know where that PHI is located, we will tell you how to redirect your request.

Amendment

If you believe that your PHI maintained by DERMIO is incorrect or incomplete, you may ask us to correct your PHI. Your request must be made in writing to the Health Information Management Department, and it must explain why you are requesting an amendment to your PHI. We generally can deny your request if your request relates to PHI: (i) not created by DERMIO; (ii) not part of the records DERMIO maintains; (iii) not subject to being inspected by you; or (iv) that is accurate and complete. If your request is denied, we will provide you a written denial that explains the reason for the denial and your rights to: (i) file a statement disagreeing with the denial; (ii) if you do not file a statement of disagreement, submit a request that any future disclosures of the relevant PHI be made with a copy of your request and DERMIO’s denial attached; and (iii) complain about the denial.

Accounting of Disclosures.

You generally have the right to request and receive a list of the disclosures of your PHI we have made at any time during the six (6) years prior to the date of your request (provided that such a list would not include disclosures made prior to April 14, 2003). The list will not include disclosures made at your request, with your authorization, and does not include certain uses and disclosures to which this Notice already applies, such as those: (i) for treatment, payment, and health care operations; (ii) made to you; (iii) for DERMIO’s patient list; (iv) for national security or intelligence purposes; or (v) to law enforcement officials. You should submit any such request to DERMIO’s Privacy Officer. DERMIO will provide the list to you at no charge, but if you make more than one request in a year you will be charged a fee of the costs of providing the list.

Right to Copy of Notice

You have the right to receive a paper copy of this notice upon request. To obtain a paper copy of this notice, please contact the Privacy Officer at: Privacy Officer, Dermio, LLC, 3023 N. Clark St., Ste. 861, Chicago, IL 60657, 312-206-36

Right to File A Complaint.

You may complain to DERMIO if you believe your privacy rights with respect to your PHI have been violated by contacting or writing to: Privacy Officer, Dermio, LLC, 3023 N. Clark St., Ste. 861, Chicago, IL 60657, 312-206-3653. You also have the right to file a complaint with the Secretary of the Department of Health and Human Services, Office for Civil Rights. You will not be penalized for filing a complaint. You may contact the Office for Civil Rights at:

Office for Civil Rights
U.S. Department of Health and Human Services
233 N. Michigan Ave., Suite 240
Chicago, IL 60601
T: (800) 368-1019
F: (312) 886-1807
Contact the Privacy Officer at Dermio, LLC, 3023 N. Clark St., Ste. 861, Chicago, IL 60657, 312-206-3653 if you have questions about this Notice.