Security Risks

Most standard email providers such as Gmail, Yahoo, Hotmail, etc. do not provide a secured or encrypted means of communication. As a result, there is risk that any protected health information contained in an email may be disclosed to, or intercepted by, unauthorized third parties. Additionally, email messages accessible through personal computers, laptops, or phones have inherent privacy risks especially when the email account is provided by an employer, when the account is not password protected, or the account is shared. Use of more secure communications, such as phone, fax or mail is preferred and always an available alternative.

Responsibility

When consenting to the use of email through such unsecured or unencrypted systems, you are accepting responsibility for any unauthorized access or disclosure to protected health information contained within the message. The Practice will not be responsible for unauthorized access of protected health information while in transmission and will not be responsible for safeguarding information once it is delivered. The Practice will take steps to ensure that any email with protected health information is protected prior to being sent to the requested address and will use the minimum necessary amount of protected health information when communicating with you.

Additional Information

It is important to understand that emails will not be used to replace or facilitate communications between you and your physician and will not be considered private communications. There is no guarantee that the Practice will be actively monitoring the inbox so responses and replies sent to or received by you or the Practice may be hours or days apart. Email messages may be inadvertently missed or errors in transmissions may occur. The Practice will not be responsible for any issues caused by delays in communications. If you have an immediate need or an emergency situation, you must contact the Practice by telephone or dial 9-1-1 if applicable. Practice staff will be utilized to monitor the inbox in order to properly direct or respond to communications received. Therefore, any information considered sensitive should not be included in your communications.

At the Practice’s discretion, any email message received or sent may become part of your medical record.

HIPAA PATIENT CONSENT FORM

Our Notice of Privacy Practices provides information about how we may use and disclose protected health information about you. The Notice contains a Patients Rights section describing your rights under the law. You have the right to review our Notice before signing this Consent. The terms of our Notice may change. If we change our Notice, you may obtain a revised copy by contacting our office, or going to our Website.

You have the right to request that we restrict how protected health information about you is used or disclosed for treatment, payment or health care operations.

By signing this form, you consent to our use and disclosure of protected health information about you for treatment, payment and health care operations. You have the right to revoke this Consent, in writing, signed by you. However, such revocation shall not affect any disclosures we have already made in reliance on your prior Consent. The Practice provides this form to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

The Patient understands that:

x Protected health information may be disclosed or used for treatment, payment or health care operations.

x The Practice has a Notice of Privacy Practices and that the patient has the opportunity to review this Notice.

x The Practice reserves the right to change the Notice of Privacy Policies.

x The Patient has the right to restrict the uses of their information.

x The Patient may revoke this Consent in writing at any time and all future disclosures will then cease.

x The Practice may condition treatment upon execution of this Consent. No insurance can be billed on the patient’s behalf without this signed HIPAA consent form, therefore same day of service payment in full for any services will be required.

GENERAL PHOTOGRAPH/VIDEO RELEASE FORM

I hereby give my consent for SkinPhysicians & Surgeons, Inc., its subsidiaries, licensees, successors and assignees, the right to use, publish and reproduce pictures of me in film or electronic (video) form, and sound and video recordings of my voice , depicting before, during, and after treatment for procedure, performed , for the purpose of being displayed in albums to be shared with prospective patients or via the Internet within medical education settings. I also agree to the use of my photographs and/ or video for general advertising and promotional purposes in any and all media including but not limited to print media, cable and broadcast television, the Internet, social media, brochures and educational seminars. This permission extends to all languages, media, formats, markets and geographies now known or hereafter devised. I understand and agree that these images may be used for an indefinite period of time by SkinPhysicians & Surgeons, Inc., its subsidiaries, licensees, successors and assignees.

I understand that my name will not be revealed therein or by descriptive text or commentary, and when possible, eyes will be obscured to retain privacy. I understand that my image may be edited, copied, exhibited, published or distributed and waive the right to inspect or approve the finished product wherein my likeness appears. Additionally, I waive any right to royalties or other compensation arising or related to the use of my image or recording.

The undersigned releases SkinPhysicians & Surgeons, Inc., its subsidiaries, licensees, successors and assignees, from all claims for libel, slander, invasion of privacy, infringement of copyright or right of publicity, or any other claim related to the image or voice recordings. This release includes without limitation any claims related to blurring, distortion, alteration, optical illusion, digital alteration, use in composite form, whether intentional or otherwise, or use of a fictitious name, that may occur or be produced in the processing or publication of the image and/or voice.

By signing this form I acknowledge that I have completely read and fully understand the above release and agree to be bound thereby.