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MELBOURNE, 675 S Babcock St. Suite 200, Melbourne, FL 32901TAMPA, 14499 North Dale Mabry Hwy Tampa, Suite #129-S FL 33618PALM BAY, 5200 Babcock St. Suite 106, Palm Bay, FL 32905TAMPA, Inside TLC Medical Office, 10866 Sheldon Rd, Tampa, FL 33626TAMPA, 375 S 12Th Street, Tampa FL 33602ROCKLEDGE, 1019 Harvin Way, Rockledge, FL 32955

Notice of Privacy Practices Summary & Receipt of Written Acknowledgement Form

This summary of our privacy practices contains a condensed version of our Notice of Privacy Practices.

Our full length notice is available upon request. PLEASE REVIEW IT CAREFULLY. Effective Date: Today

This notice describes how medical information about you may be used and disclosed & how you may gain access to this information. We understand that your medical information is personal to you, and we are committed to protecting your information. As our patient, we create medical records about your health, our care for you, and the services and/or items we provide to you as our patient. By law, we are required to make sure that your Protected Health Information is kept private.

How will we use or disclose your information? Here are a few examples:

For Medical treatment
To obtain payment for our services
In emergency situations
For appointment & patient recall reminders
To run our Practice more efficiently & ensure all our patients receive quality care

To avert a serious threat to health or safety
For organ and tissue donation
For workers' compensation programs
In response to certain requests arising out of lawsuits or other disputes

If you believe your privacy rights have been violated, you may file a complaint with the Practice or with the Secretary of the Department of Health and Human Services. To file a complaint with the Practice, contact our office manager. All complaints must be submitted in writing. You will not be penalized for filing a complaint.

You have certain rights regarding the information we maintain about you. These rights include:

The right to inspect and copy
The right to amend
The right to an accounting of disclosures

The right to request restrictions
The right to a paper copy of this notice
The right to request confidential communications

WRITTEN ACKNOWLEDGEMENT

I hereby acknowledge receipt of Indigo Dermatology’s Notice of Privacy Practices.

Name

I am a parent/legal guardian of

I hereby acknowledge receipt of Indigo Dermatology’s Notice of Privacy Practices with respect to the patient.

Name

Relationship to Patient

Signature of Patient or Person Authorized to Sign for Patient

Date

When you submit, your form will be sent to a HIPAA secure account.