Your Information. Your Rights. Our Responsibilities.

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

Your Rights

You have the right to:

• Get a copy of your paper or electronic medical record

• Correct your paper or electronic medical record

• Request confidential communication

• Ask us to limit the information we share

• Get a list of those with whom we’ve shared your information

• Get a copy of this privacy notice

• Choose someone to act for you

• File a complaint if you believe your privacy rights have been violated

Your Choices

You have some choices in the way that we use and share information as we:

• Tell family and friends about your condition

• Provide disaster relief

• Include you in a hospital directory

• Provide mental health care

• Market our services and sell your information

• Raise funds

Our Uses and Disclosures

We may use and share your information as we:

• Treat you

• Run our organization

• Bill for your services

• Help with public health and safety issues

• Do research

• Comply with the law

• Respond to organ and tissue donation requests

• Work with a medical examiner or funeral director

• Address workers’ compensation, law enforcement, and other government requests

• Respond to lawsuits and legal actions

To the extent that we have your substance use disorder patient records, subject to 42 CFR part 2, we will not share that information for investigations or legal proceedings against you without (1) your written consent or (2) a court order and a subpoena.

Your Rights

When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.

Get an electronic or paper copy of your medical record

• You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this.

• We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.

Ask us to correct your medical record

• You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this.

• We may say “no” to your request, but we’ll tell you why in writing within 60 days.

Request confidential communications

• You can ask us to contact you in a specific way (for example, home, office, or cell phone) or to send mail to a different address.

• We will say “yes” to all reasonable requests.

Ask us to limit what we use or share

• You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say “no,” for example, if it could affect your care. If we agree to your request, we may still share this information in the event that you need emergency treatment.

• 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 say “yes” unless a law requires us to share that information.

Get a list of those with whom we’ve shared information

• You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why.

• We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.

Get a copy of this privacy notice

You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.

Choose someone to act for you

• If someone has authority to act as your personal representative, such as if someone has your medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.

• We will make sure the person has this authority and can act for you before we take any action.

File a complaint if you feel your rights are violated

• You can complain if you feel we have violated your rights by contacting us using the information on this web page.

• You can file a complaint with the 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 https://www.hhs.gov/hipaa/filing-a-complaint/index.html.

• We will not retaliate against you for filing a complaint.

Your Choices

For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.

In these cases, you have both the right and choice to tell us to:

• Share information with your family, close friends, or others involved in your care or payment for your care

• Share information in a disaster relief situation

• Include your information in a hospital directory
  
  If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.

In these cases we never share your information unless you give us written permission:

• Marketing purposes

• Sale of your information

• Most sharing of psychotherapy notes

In the case of fundraising:

• We may contact you for fundraising efforts, but you can tell us not to contact you again.

Our Uses and Disclosures

We typically use or share your health information in the following ways.

Treat you

We can use your health information and share it with other professionals who are treating you.

Example: A doctor treating you for an injury asks another doctor about your overall health condition.

Run our organization

We can use and share your health information to run our practice, improve your care, and contact you when necessary.

Example: We use health information about you to manage your treatment and services.

Bill for your services

We can use and share your health information to bill and get payment from health plans or other entities.

Example: We give information about you to your health insurance plan so it will pay for your services.

How else can we use or share your health information?

We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes.  

In all cases, including those listed below, if we have substance use disorder patient records about you, subject to 42 CFR part 2, we cannot use or share information in those records in civil, criminal, administrative, or legislative investigations or proceedings against you without (1) your consent or (2) a court order and a subpoena.

Help with public health and safety issues

We can share health information about you for certain situations such as:

• Preventing disease

• Helping with product recalls

• Reporting adverse reactions to medications

• Reporting suspected abuse, neglect, or domestic violence

• Preventing or reducing a serious threat to anyone’s health or safety

Do research

We can use or share your information for health research.

Comply with the law

We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law.

Respond to organ and tissue donation requests

We can share health information about you with organ procurement organizations.

Work with a medical examiner or funeral director

We can share health information with a coroner, medical examiner, or funeral director when an individual dies.

Address workers’ compensation, law enforcement, and other government requests

We can use or share health information about you:

• For workers’ compensation claims

• For law enforcement purposes or with a law enforcement official

• With health oversight agencies for activities authorized by law

• For special government functions such as military, national security, and presidential protective services

Respond to lawsuits and legal actions

• We can share health information about you in response to a court or administrative order, or in response to a subpoena.

Our Responsibilities

• We are required by law to maintain the privacy and security of your protected health information.

• We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.

• We must follow the duties and privacy practices described in this notice and give you a copy of it.

• We will not use or share your information other than as described in this notice unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.

For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.

Changes to the Terms of this Notice

We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our web site.

Nightingale Dermatology PLLC utilizes SMS messaging (text messages) to facilitate communication regarding appointment reminders, appointment changes or cancellations, account or care-related notifications, or administrative messages related to the services provided to current or future patients. Providing consent to receive text messages is not a condition of receiving care or services.

Text Message Details
Message frequency may vary and standard message and data rates may apply based on mobile carriers and plans. Mobile carriers are not liable for delayed or undelivered messages. SMS messages are used for scheduling, administrative activities, and care-related communications. SMS opt-in and consent data will not be shared with any third parties.

Opt-Out and Help
I understand that I may revoke my consent at any time by texting "STOP" to (206) 929-4707. After opting out, I will receive a confirmation message confirming that I have been unsubscribed. For assistance, I may text "HELP" or contact Nightingale Dermatology, PLLC at (206) 929-4707.

Text Message Origin
I understand that SMS text messages from Nightingale Dermatology, PLLC may originate from the following organizational phone numbers:

• (206) 929-4707

Please see the above “Notice of HIPAA Privacy Policy” link for additional information on Privacy Practices.

We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our web site.

We respect your privacy and are committed to protecting your personal information. Any information collected as part of our SMS or text messaging program, including mobile phone numbers, messaging consent, and opt-in data, is used solely for the purpose of providing the messaging services you have opted-in to receive. No mobile opt-in data or text messaging consent information will be shared, sold, rented, or disclosed to any third parties, except as required to deliver the messaging service or to comply with applicable laws.

SMS is opt-in only, and consent for SMS is not shared, sold or used for marketing purposes.

Personal data obtained by SMS may include name, date of birth, and appointment date and time. It will be used to confirm appointments, send billing reminders, or for health-related issues, such as care reminders.

Specific patient healthcare information is discouraged from being sent by SMS messaging. We offer a HIPAA compliant messaging system through the Spruce app for sending any protected health information.

Patient information will not be shared with third parties except as necessary to provide healthcare services associated with Nightingale Dermatology.

By opting in, you agree to receive SMS text messages from Nightingale Dermatology PLLC related to services that we are providing to you. Message and data rates may apply, and message frequency varies. You may text us STOP at any time to opt out of receiving SMS text messages from us. You may text us HELP at any time to receive help. Carriers are not liable for any delayed or undelivered messages.

We protect your information using encryption, secure servers, and restricted access controls. Our team follows strict data handling procedures to keep your information safe.

This policy may be updated as needed. The new notice will be available upon request, in our office, and on our web site.

PAYMENT AT TIME OF SERVICE: Payment is due in full at the time of service. You will be charged a $25 service fee for any returned checks, no exceptions.

INSURANCE: Patients will be asked to upload a copy of their insurance card to the online portal. This is not for billing purposes, but as a courtesy to include with any specimens that are sent out for processing. Specimens sent out for processing (such as biopsies and cultures) will be billed to the patient separately by the processing lab (such as LabCorp), and are not included in any payments made to Nightingale Dermatology PLLC. It is your responsibility to contact your insurance company for reimbursement for payments of services rendered at Nightingale Dermatology PLLC.

Nightingale Dermatology PLLC serves as an out-of-network provider, and reimbursement for any payments made to this clinic by the patient are solely the patient’s responsibility. We will make best efforts to provide documentation to help support a patient’s desire to submit payment to their insurance carrier for reimbursement. Any charges that are not reimbursed by your insurance policy are your (the patient’s) responsibility.

You will notify Nightingale Dermatology PLLC if you are covered under Medicare, Medicaid, or other commercial insurance plan, to allow Nightingale Dermatology PLLC to stay compliant with state and federal requirements.

Your insurance policy is a contract between you and your insurance company. Any pre-certifications of procedures or testing are your responsibility. Please let us know in advance if your insurance company requires this.

COLLECTIONS: Please note, in the rare case that payment is not made at the time of service, and if payment is not received from within 60 days from the date of service(s), your account will be considered delinquent and subject to referral to an outside collection agency.Item description

Each time a patient misses an appointment without providing proper notice, another patient is prevented from receiving care. Therefore, patients who do not show up for their appointment without a call to cancel at least 24 hours before the appointment time will be considered as no- shows or last-minute-cancellations.

Nightingale Dermatology PLLC has the right to charge a fee of $100.00 for all missed appointments ("no shows"), and a $50.00 fee for all cancellations within 24 hours of a scheduled appointment (“last-minute-cancellations”).

These fees will be billed to the patient as applicable. This fee is not covered by insurance and must be paid in full prior to your next appointment.

Thank you for your understanding and cooperation as we strive to best serve the needs of all our patients.