1C Commons Drive, Suite 16
Londonderry, NH 03053

Notice of Privacy Practices



If you have any questions about this Notice, please contact our Privacy Officeat the number listed at the end of this Notice.


Each time you visit a healthcare provider, a record of your visit is made.  Typically, thirecord contains your symptoms, examination and tesresults, diagnoses, treatment, a plafor future care or treatment, and billing- related information.  This Notice applies to all of the records of your care generated by your health care provider.



Our Responsibilities


Derry Dermatology PLLC is required by law to maintain the privacy of your health information and to provide you with a description of our legal duties and privacy practices regarding your health information.  The currennotice will be posted in the main reception area.  The notice will include the effective date. In addition, we will make our best effort to provide you with a copy of this noticthat we request you acknowledge with your signature.


We are required by law to abide by the terms of this Notice and  notify  yoif wmake  changes  to this  Notice,  which may  be at any  time.  Changes to thNotice will apply  to your medical information  that we already  maintain  as well as new information received after the change occurs. If we change our Notice, it will be posted in the main reception area.  You may also request that a revised Notice be sent to you in the mail or you may ask for one at your next appointment or appropriate visit. This Notice will also serve to advise you as to your rights with regard to your medical information.


How We May Use and Disclose Medical Information About You.


The following categories describe examples of the way we use and disclose medical information:


For Treatment: We may use medical information about you to provide, coordinate and manage your treatment or services. We may disclose medical information about you to other doctors, nurses, technicians (e.g. clinical laboratories or imaging companies), medical students, or other personnel who are involved in your care.  We may communicate your informatioeither orally or in writing by mail or facsimile.

We may also provide a subsequent healthcarprovider with copies of various reports that should assist him or hein treating you. For example, your medical information may be provided to a care provider to whom you have been referred so as to ensure that the doctohas appropriate information regarding your previous treatment and diagnosis.


For Payment: We may use and disclose medical information about your treatment and services tbill and collect payment from you, your insurance company or a third party payer For example, we may need to give your insurance company information beforit approves or pays for the health care services we recommend for you.


For Health Care Operations:  We may use or discloseas needed, your health informatioin order to support our business activities. These activities may include, but are not limited to quality assessment activities, employee review activities, licensing, legal advice, accounting support, information systems support and conducting oarranging for other business activitiesIn addition, we may also call you by name in the waiting room when your care provider is ready to see you. We may use or disclose your protected healtinformation, as necessary, to contact you to remind you of your appointment by telephone or reminder card.


Business Associates:  There  are somservices  provided  in our organizatiothrough contracts with business associates. Examples include billing and collection and software support. If these services are contracted, we may disclose your health informatioto our business associatso that they can perform the job that we have asked them to do and bill you or your third-party payefor services rendered. To protect your health information, however, we require the business associate to appropriately safeguard your information through a written contract. (Business Associate Agreement)


Other Permitted and Required Uses and Disclosures That May Be Made With Your Consent, Authorization or Opportunity to Object

We also may use and disclose your health information as set forth below. You have the opportunity to agree or object to the  use  or  disclosurof  all  or  part  of  your  health information in these instances. If you are not present or able to agree or object to the use or disclosure of the health information (such as in an emergency situation), then your clinician may, using professional judgment, determine whether the disclosure is in your best interest. In this case, only the information that is relevant to your health care will be disclosed.


Individuals Involved in Your Care or Payment for Your Care: Unless you object, we may release medical informatioabout you to a friend or family member who is involved in your medical care, or who helps to pay for your care. In addition, we may disclosmedicainformation about you to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status and location.


Future  Communications:  We may communicate  to  you via newsletters, mailings or other means regarding treatment options,  information  on health-related benefits or services; tremind you that  you have an  appointment  for  medical care; or other community based  initiatives  or activities in which our facility is participating If you are not interested in receivinthese materialsplease contact our Privacy Officer.


Other Permitted  and  RequireUses  and Disclosures That May Be Made Without Your Authorization or Opportunity  to Object


We may use or disclose your health information in the following situations without youauthorization or without providing you with aopportunity tobjectThese situations include:


As required by law: We may use and disclose health information to the following types of entities, includinbut not limited to:

•     Food and Drug Administration

•      Public   HealtoLegaAuthoritiechargewith preventing or controlling disease, injury or disability

•     Correctional Institutions

•     Workers Compensation Agents

•     Organ and Tissue Donation Organizations

•     Military Command Authorities

•     Health Oversight Agencies

•     Funeral Directors, Coroners and Medical Directors

•     National Security and Intelligence Agencies

•     Protective Services for the President and Others

•     Authority that receives reports on abuse and neglect


Law Enforcement/Legal Proceedings: We may disclose healtinformation for law enforcement   purposeas required by law or in response to a valid subpoena or court order.


State-Specific Requirements: Many states have requirements for reporting which may include population- based activities relating timproving health or reducing health care costs, cancer registries, birth defect registries and others.


Your Health Information  Rights

Although your health record is the physicaproperty of the practice that compiled it, you have the right to:


Inspect and Copy: You have the right to inspect and copy medical information that may be used to make decisions about your care. We ask that you submit your request in writing Usually, this includes medical and billing records, but does not include psychotherapy notes or information compiled in reasonablanticipation of, or for use in, a civil, criminal, or administrative action or proceeding.  Wmay deny your request to and copy in certaivery limited circumstances. If you are denieaccess to medical information, you may request that the denial be reviewed. The person conducting the review will not bthe person who denied your request. We will comply with the outcome of the review.   Requests for access to and copies of your medical information must be submitted to Derry Dermatology PLLC iwriting.  There will be a fee charged up to the maximuamount  as prescribed by governing law.


Amend: If you feel that medical informatiowe have about you is incorrect or incompleteyou may ask us to amend the information by submitting a request in writing.  You have the right to request an amendment for as long as we keep thinformation.  Wmay deny yourequesfoan amendment anif this occurs, you will be notified of the reason for the denial.


An  Accounting  of  Disclosures You  have the right to request an accountinof our disclosures of medical information about you except for certain circumstances, including disclosures for treatment, payment, health care operationowhere you specificallauthorized a disclosure. Derry Dermatology PLLC will provide the first accounting to you in any 12- month period without charge, upon your written request. The cost for subsequent requests for an accounting within the 12-month period will be up to the maximum amount prescribed by governing law.


RequesRestrictions: You have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment, payment or health care operations. You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend.  If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will agree unless a law requires us to share that information For example, you could ask that we not use or disclose information about a procedure that you had. We ask that you submit these requests in writing.


We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you with emergency treatment.


Request ConfidentiaCommunications: You have the right to reques thawe communicate with you about medical matters in a certain way or at a certain location. We will agree to the request to the extent that it is reasonable for us tdo so.  For example, you can ask that we use an alternative address for billing purposes. We asthayou submit these requests in writing.


A  Paper Copy oThis  Notice:  You have the right to a paper copy of this  notice. You may ask us to give you a copy of this notice at any time. To exercise any of yourights, please submit your request in writing to the practice’s privacy officer indicated below.




If you believyour privacrights have been violated,  you may file a complaint with us by calling (603) 956-3551 and asking for the Privacy Officer or by contacting U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/.   You will not be penalized for filing a complaint.


Other Uses of Medical Information


Otheuses and disclosureof medical informationot covered by this Noticor the laws that apply to us will be made only with your written permission. If you provide us permission tuse or disclose medical information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose medical information about you for the reasons covered by your written authorization. However, we are unable to take back any disclosures we have already made with your permission and ware required to retain our records of the care that we provided to you.


Privacy Officer: Dr. E Zabawski, 603-965-3551

Updated 1/18/2020


Website Builder