Patient Handouts : Notice of Privacy Practices

As of April 14, 2003 a federal regulation (HIPAA) requires that medical practices post a notice of privacy practices, describing how private medical information is handled by the practice, and in what ways that information may be required to be disclosed. More information about HIPAA can be found at

Notice of Privacy Practices

Pioneer Valley Dermatology, p.c.

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. If you have any questions about this Notice, please contact our Privacy Contact, Dr. Richard Wyatt.

"Protected Health Information" (PHI) is information about you, including demographic information and even your name, that may identify you and that relates to your health and health care services.

Pioneer Valley Dermatology is required to abide by this policy, but we may also change the policy from time to time. The current policy will be posted prominently in our office and on our web site, can be downloaded from our web site ( or requested from our office.

Your PHI may be used and disclosed to help in your treatment, to get payment for services provided to you, and as may be needed to operate this practice:

  1. Treatment: We may need to discuss your PHI with others who are involved in your health care--for example, your other doctors, your pharmacy, or family members especially if they help in your care.
  2. Payment: We may disclose your PHI to collect payment for our services, for example to your insurance company, or family members if they are responsible for your bill. We also use a billing service, whose employees have access to some of your PHI.
  3. Health Care Operations: In order to operate our business there are many needs to disclose PHI. For example, calling your name in the waiting room, or evaluating the quality of your care such as an independent chart review. We might contact you by mail or telephone or email notifying you of an appointment or of the results of a biopsy or lab tests. We might leave such information on your answering machine or voicemail. We might use your name and address to send you announcements about our business, or changes in services.

There are other circumstances when we may disclose specific PHI:

  1. When specifically authorized by you. Most disclosures would require authorization by you, and you may be inconvenienced by needing to sign forms specifying what information we can release to whom (for example, for a school physical, or to release your chart information as a requirement for a life insurance policy.)
  2. WITHOUT your authorization. Here are some situations in which we may disclose information about you even if you do NOT want us to do so:
    1. Public Health: Public Health Officials or the Food & Drug Administration may request information for public health reasons (for example, controlling disease, injury, disability, or adverse events from drugs or medical products.)
    2. Communicable Diseases: If authorized by law we may disclose information to a person who is at risk of contracting or spreading a communicable disease.
    3. Health Oversight: A health oversight agency for activities authorized by law (audits, investigations, inspections). These include government agencies that oversee the health care system, benefit programs, regulatory programs and civil rights laws.
    4. Abuse or Neglect: We are required to disclose suspected child abuse or neglect to a public health authority; in addition we may disclose your information to the appropriate governmental entity if we believe that you have been a victim of abuse, neglect or domestic violence.
    5. Legal Proceedings: We may disclose PHI in the course of a judicial or administrative proceeding, in response to a court order, subpoena, discovery request or other lawful process.
    6. Law Enforcement: We may disclose PHI for law enforcement purposes as long as applicable legal requirements are met, including (a) legal processes and as otherwise required by law, (b) limited information requests for identification and location purposes pertaining to victims of a crime, (c) suspicion that death has occurred as a result of criminal conduct, (d) in the event that a crime occurs on the premises of the practice, or (e) medical emergency in which it is likely that a crime has occurred.
    7. Coroners, Funeral Directors, and Organ Donation: We may disclose PHI for purposes relevant to their duties.
    8. Criminal Activity: Depending on federal and state laws, we may disclose PHI if we believe that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public.
    9. Military Activity and National Security: We may disclose your PHI if you are a member of U.S. or foreign military forces (including veterans) if required by the appropriate authorities.
    10. Workers' Compensation: PHI may be disclosed as authorized to comply with workers' compensation laws and similar programs.
    11. Inmates: We may disclose your PHI if you are an inmate of a correctional facility and we created or received your PHI in the course of providing care to you.


You have the following rights regarding the information that we maintain about you:

  1. Confidential Communications. You have the right to request that our practice communicate with you about your health and related issues in a particular manner or at a certain location. For instance, you may ask that we contact you at home, rather than work. In order to request a specific type of confidential communication, you must make a written request to Dr. Wyatt specifying the requested method of contact, or the location where you wish to be contacted. Our practice will accommodate reasonable requests. You do not need to give a reason for your request.
  2. Requesting Restrictions. You have the right to request a restriction in our use or disclosure of your PHI for treatment, payment or health care operations. Additionally, you have the right to request that we restrict our disclosure of your PHI to only certain individuals involved in your care or the payment for your care, such as family members and friends. We are not required to agree to your request; however, if we do agree, we are bound by our agreement except when otherwise required by law, in emergencies, or when the information is necessary to treat you. In order to request a restriction in our use or disclosure of your PHI, you must make your request in writing to Dr. Wyatt. Your request must describe in a clear and concise fashion:
    1. the information you wish restricted;
    2. whether you are requesting to limit our practice's use, disclosure or both; and
    3. to whom you want the limits to apply.
  3. Inspection and Copies. You have the right to inspect and obtain a copy of the PHI that may be used to make decisions about you, including patient medical records and billing records. You must submit your request in writing to Dr. Wyatt in order to inspect and/or obtain a copy of your PHI. Our practice may charge a fee for the costs of copying, mailing, labor and supplies associated with your request. Our practice may deny your request to inspect and/or copy in certain limited (and highly unusual) circumstances; however, you may request a review of our denial. Another licensed health care professional chosen by us will conduct reviews.
  4. Amendment. You may ask us to amend your health information if you believe it is incorrect or incomplete, and you may request an amendment for as long as the information is kept by or for our practice. To request an amendment, your request must be made in writing and submitted to Dr. Wyatt. You must provide us with a reason that supports your request for amendment. Our practice will deny your request if you fail to submit your request (and the reason supporting your request) in writing. Also, we may deny your request if you ask us to amend information that is in our opinion: (a) accurate and complete; (b) not part of the PHI kept by or for the practice; (c) not part of the PHI which you would be permitted to inspect and copy; or (d) not created by our practice, unless the individual or entity that created the information is not available to amend the information.
  5. Accounting of Disclosures. All of our patients have the right to request an "accounting of disclosures." An "accounting of disclosures" is a list of certain non-routine disclosures our practice has made of your PHI for non-treatment or operations purposes. Use of your PHI as part of the routine patient care in our practice is not required to be documented. For example, the doctor sharing information with the medical assistant; or the billing department using your information to file your insurance claim. In order to obtain an accounting of disclosures, you must submit your request in writing to Dr. Wyatt. All requests for an "accounting of disclosures" must state a time period, which may not be longer than six (6) years from the date of disclosure and may not include dates before April 14, 2003. The first list you request within a 12-month period is free of charge, but our practice may charge you for additional lists within the same 12-month period. Our practice will notify you of the costs involved with additional requests, and you may withdraw your request before you incur any costs.
  6. Right to a Paper Copy of This Notice. You are entitled to receive a paper copy of our notice of privacy practices. The simplest way to get a copy of it is to print it off our web site, You may ask us to give you a copy of this notice at any time. To obtain a paper copy of this notice, contact anyone in our office.
  7. Right to File a Complaint. If you believe your privacy rights have been violated, you may file a complaint with our practice or with the Secretary of the Department of Health and Human Services. To file a complaint with our practice, contact Dr. Wyatt. All complaints must be submitted in writing. You will not be penalized for filing a complaint.
  8. Right to Provide an Authorization for Other Uses and Disclosures. Our practice will obtain your written authorization for uses and disclosures that are not identified by this notice or permitted by applicable law. Any authorization you provide to us regarding the use and disclosure of your PHI may be revoked at any time in writing. After you revoke your authorization, we will no longer use or disclose your PHI for the reasons described in the authorization. Please note, we are required to retain records of your care.

Again, if you have any questions regarding this notice or our health information privacy policies, please contact Dr. Wyatt; the office number is 413-549-7400.

Last revised 4/14/2003