Dimmick Laughlin Dermatology LLC
Notice of Privacy Practices:

To our patients:
This notice describes how medical information about you may be used and disclosed and how you can get access to your

Health Care Providers Covered by this Notice: This notice covers Dimmick Laughlin Dermatology LLC and their employees,
students, volunteers, and trainees.

Our Obligations
By law, Dimmick Laughlin Dermatology LLC must keep protected health information (PHI) private. PHI is any information,
including verbal, electronic and on paper that is created or received by Dimmick Laughlin Dermatology LLC for purposes of
providing health care to patients and for purposes of billing and payment for those services. PHI includes test results, notes
written by doctors and nurses and general information such as your name, address, and telephone number that is included in
your healthcare and billing records.

Dimmick Laughlin Dermatology LLC, by law, must give you this notice and to follow the terms and conditions of the notice
that is currently in effect. Dimmick Laughlin Dermatology LLC will report breaches of your unsecured PHI as required by

How Dimmick Laughlin Dermatology LLC fulfills these Obligations:

  • Our practice is dedicated to maintaining the privacy of your PHI.
  • Our practice takes necessary precautions against inappropriate use or disclosure of PHI.
  • Employees are expected to access PHI only as necessary to perform their jobs.

Use and Disclosure of your Health Information

The following describes the most common circumstance in which Dimmick Laughlin Dermatology LLC may use or disclose
protected health information:

A. For Treatment: We may share PHI about you with other professionals involved in your care, such as your referring

B. For Payment: We may use and disclose your PHI for billing purposes, such as sending information to your insurance
company to receive payment for your services.

C. For Healthcare Operations: We may use and disclose PHI about you to run our practice, improve your care, and
contact you when necessary.

Other Uses and Disclosures of PHI without your permission:

  • To public health authorities such as to report the occurrence of communicable diseases.
  • When required by federal, state, or local law or regulations.
  • When necessary to reduce or prevent a serious health or safety threat.
  • If you are a member of the armed forces if required by the appropriate authorities.
  • For Workers Compensation and similar programs.

Uses and Disclosures Requiring your Written Permission: For any purpose other than the ones listed earlier in this notice, we
may use or share your PHI only when you give us written permission.

Your Rights  

A. Revoking your Authorization: If you give us written permission to use and share your PHI, you can take back your
permission at any time, as long as you tell us in writing. If you take back your permission, we will stop using or
sharing your information, but we will not be able to take back any information that we have already shared.

B. Right to Request Restrictions: You have the right to request a restriction or limitation on the medical information we
use or disclosure about you for treatment, payment, or health care operations. Additionally, you have the right to
request that we restrict our disclosure of your health information 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. Your restriction request must be in writing and specifically tell us what
information you want to limit, whether you want us to limit our use, disclosure, or both and to whom you want the
limits to apply.

C. Right to Request Confidential Communication: You have the right to request PHI in a certain form or at a specific
location; this request must be in writing. For instance, you may request that we contact you at home, rather than work.
We will agree to reasonable requests.

D. Right to Inspect and Copy: You have the right to review and/or obtain a copy of your PHI; this request must be in

E. Right to Amend: You have the right to ask us to amend your health information if you believe it is incorrect or
incomplete; this request must be in writing. Your request must provide a reason for the change. We can deny the
request if: 1) it is not in writing or does not include a reason for the change; 2) the information you want to change was
not created by us; 3) the information is not part of the medical record kept by our practice; 4) the information is not part
of the information that you are permitted to inspect or copy; or 5) the information contained in the record is accurate
and complete.

F. Right to Breach Notification: We are required by law to tell you if we become aware that your medical information has
been improperly disclosed or otherwise subject to a “breach” as defined in and/or required by HIPAA and applicable
state law.

G. Right to an Accounting of Disclosures: You have a right to request an accounting of disclosures of your PHI. This list
of disclosures will not be greater than a time period of six years from the date of your request, but does not include
disclosures for Treatment, Payment, or Health Care Operations (as described in Section Your Rights A, B, and C of this
Notice). Your request must be in writing and must state the time period for the requested information.

H. Right to Copy of This Notice: You have the right to a copy of this Notice of Privacy Practices. You may ask us to give
you a copy of this Notice at any time.

I. Privacy Complaints: If you believe your privacy rights as described in this notice have been violated, you may file a
complaint with our practice at the following address or phone number: Dimmick Laughlin Dermatology LLC, Attn:
HIPAA Officer, 1530 E. Primrose, Suite D, Springfield, MO 65804. Telephone 417-882- 1818. You also have the
right to file a complaint with the Secretary of the Department of Health and Human Services. All complaints must be
submitted in writing. You will not be penalized for filing a complaint.

If you have any questions regarding this notice or our health information privacy policies, please contact our Privacy
Officer at 417-882- 1818. We reserve the right to revise this notice at any time without notification. Effective Date: