We would love to have you in for a skin analysis and consultation. During this time we will partner with you to design a customized treatment plan that will best meet your expectations. Consultations not available for Dermatology or Testosterone issues.
Appointments are preferred, but not always necessary. If we have an available Medical Aesthetician, we will be happy to provide your desired treatment.
Please arrive at least 10 minutes prior to your scheduled appointment time. Since we are a medical spa we require that all new patients fill out skin care history information and treatment consent forms.
Cancellation / No Show Policy for Appointments
We understand that there are times when you must miss an appointment due to emergencies or obligations for work or family. However, when you do not call to cancel an appointment, you may be preventing another patient from getting much needed treatment.
Conversely, the situation may arise where another patient fails to cancel and we are unable to schedule you for a visit, due to a seemingly “full” appointment book.
If an appointment is not cancelled at least 24 hours in advance you will be charged a fifty dollar ($50) fee; this will not be covered by your insurance company.
We understand that delays can happen however we must try to keep the other patients and doctors on time.
If a patient is 15 minutes past their scheduled time we may have to reschedule the appointment.
Cancellation/ No Show Policy for Surgery
Due to the large block of time needed for surgery, last minute cancellations can cause problems and added expenses for the office.
If a surgery is not cancelled at least 3 days in advance you will be charged a seventy five dollar ($75) fee; this will not be covered by your insurance company.
We will require that patients with self-pay balances pay their account balances off prior to receiving further services by our practice.
Patients who have questions about their bills or who would like to discuss a payment plan option may call our billing company (Medisource) at 316-263-0776 and ask to speak to a representative with whom they can review their account and concerns.
Patients with balances over $100 must make payment arrangements prior to future appointments being made.
If a member does not keep or make their complimentary Microdermabrasion or Facial appointment for the month, that service can be carried over to the following month. Rescheduled appointments are subject to availability. We appreciate your understanding, value your patronage and look forward to a lasting professional relationship.
Minors are welcome for treatments if accompanied by a parent or with a prior signed waiver. For your enjoyment… we request that you leave babies and children at home.
Turn off cell phones, pagers, and ipods. This is your time to relax and be
in the moment. Inform our front desk staff if you have any special needs or concerns to
allow us to ensure your time spent with us is a memorable experience.
Gratuities are never expected, but greatly appreciated. For large parties gratuity will be automatically charged.
All returned payments are subject to a $20 fee. Cash, cashier check or money order for amount of returned payment plus fee must be brought or mailed to Derby Derm within 30 days or the returned payment will be turned over to collection agency and collection fees will apply.
We will be happy to give you the best discount available however we will not be able to
combine discounts, coupons, or special offers. Any discounted gift certificate can not be
used in conjunction with specials or other offers.
Personal belongings are the full responsibility of the spa guest.
Prices are subject to change without notice.
DERMATOLOGY, LASER CENTER, & MEDICAL DAY SPA
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN OBTAIN ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
OUR PLEDGE REGARDING YOUR HEALTH INFORMATION
Each time you visit a hospital, physician, or other healthcare provider, a record of your visit is made. Typically, this record contains your symptoms, examination and test results, diagnoses, treatment, a plan for your future care or treatment, and billing-related information. Such records are necessary for the healthcare provider to provide you with quality care and to comply with certain legal requirements.
We are committed to protecting the confidentiality of our records containing information about you. This notice applies to all records of your care created or received by this office. Other healthcare providers from whom you obtain care and treatment may have different policies or notices regarding the use and disclosure of your health information created or received by the provider. Also, health plans in which you participate may have different policies or notices concerning information they receive about you.
This notice will tell you about the ways in which we may use and disclose health information about you. We also describe your rights and certain obligations we have regarding the use and disclosure of health information.
We are required by law to maintain the privacy of your health information; give you this notice of our legal duties and privacy practices and make a good faith effort to obtain your acknowledgment of receipt of this notice; and follow the terms of the notice that is currently in effect.
HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU WITHOUT YOUR SPECIFIC AUTHORIZATION
The following categories describe different ways that we are permitted to use and disclose health information without a specific authorization from you.
We may use information about you to provide you with medical treatment or services. We may disclose health information about you to physician assistants, doctors, nurses, technicians, medical students, aestheticians, or other personnel who are involved in taking care of you at the office of Derby Derm. For example, a physician assistant treating with laser may need to know if you have cold sores because laser treatments may aggravate them. Different departments may also share health information about you in order to coordinate the different things you need, such as prescriptions or lab work. We may also disclose health information about you to other health care providers who request such information for purposes of providing medical treatment to you.
We may use and disclose health information about you so that the treatment and services you receive at our offices may be billed to and payment may be collected from you, an insurance company, or other third party. For example, we may need to give your health plan information about surgery you received so your health plan will pay us or reimburse you for the surgery. We may also tell your health plan about a treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment. We also may provide information about you to other health care providers, health plans, or health care clearinghouses to assist them in obtaining payment for treatment and service they provided to you.
For Health Care Operation
We may use or disclose, as needed, your protected health information in order to support the business activities of your physician assistant’s practice. These activities include, but are not limited to, quality assessment, activities, employee review activities, training of medical students/residents, licensing, marketing and fundraising activities and conducting or arranging for other business activities.
For example, we may disclose your protected health information to medical students/residents who see patients in our office. We may call you by name in the waiting room when your physician assistant is ready to see you.
We will share your protected health information to third party “business associates” that perform various activities (e.g., billing, transcription services) for the practice. Whenever an arrangement between our office and a business associate involves the use or disclosure of your protected health information, we will have a written contract that contains terms that will protect the privacy of your protected health information.
We may use or disclose your protected health information, as necessary, to provide you with information about treatment alternatives or other health-related benefits and services that may be of interest to you. We may also use and disclose your protected health information for other marketing activities. For example, your name and address may be used to send you a newsletter about our practice and the services we offer. We may also send you information about products or services that we believe may be beneficial to you. You may contact our Privacy Officer to request that these materials not be sent to you.
We may use and disclose health information to contact you as a reminder that you have an appointment for treatment or medical care. Unless you direct us to do otherwise, we may leave messages on your telephone answering machine identifying our office and asking for you to return our call.
There are some services provided in our organization through contracts or arrangement with business associates. For example, we may contract with a copy service to make copies of your health record. When these services are contracted, we may disclose your health information to our business associate so they can perform the job we’ve asked them to do. To protect your health information, however, we require our business associates to appropriately safeguard your information.
Individuals Involved In Your Care or Payment For Your Care: We have policies and procedures that provide for the release of information about your care or payment for such care to a member of your family, a relative, a close friend, or any other person when you are not present or able to give authorization for the release of information. If you are present for such a disclosure (whether in person or on a telephone call), we will either seek your verbal agreement to the disclosure or provide you an opportunity to object to it.
We may disclose your protected health information to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and has established protocols to ensure the privacy of your protected health information.
Consistent with applicable federal and state laws, we may disclose your protected health information, if we believe that the use or disclosure is necessary to prevent or lessen a serious threat to the health or safety of a person or the public. We may also disclose protected health information if it is necessary for law enforcement authorities to identify or apprehend an individual.
As Required By Law
We may use or disclose your health information to the extent we are required to do so by federal, state, or local law. For example, we may disclose health information about you for the following purposes:
For judicial and administrative proceedings pursuant to legal authority;
To report information related to victims of abuse, neglect or domestic violence; and
To assist law enforcement officials in their law enforcement duties.
To Avert a Serious Threat to Health or Safety
We may use and disclose health information about you if we believe in good faith that such use or disclosure is necessary to prevent or lessen a serious and imminent threat to your health and safety or the health and safety of the public or another person. Any disclosure, however, would only be to someone reasonably able to help prevent or lessen the threat.
Military and Veterans
If you are a member of the armed forces, we may release health information about you as required by military command authorities. We may also release health information about foreign military personnel to the appropriate foreign military authority.
We may release health information about you to your employer if we proved health care services to you at the request of your employer, and the health care services are provided either to conduct an evaluation relating to medical surveillance of the workplace or to evaluate whether you have a work-related illness or injury. In such circumstances, we will give you written notice of such release of information to your employer. Any other disclosures to your employer will be made only if you execute a specific authorization for the release of the information to your employer.
We may release health information about you for workers’ compensation or similar programs. These programs provide benefits for work- related injuries or illness.
Food & Drug Administration
We may disclose protected health information to a person or company required by the FDA to report adverse events, product defects or problems, biologic product deviations, and track products to enable product recalls, to make repairs or replacements or to conduct post marketing surveillance, as required.
We may disclose PHI about you for public health activities such as assisting public health authorities or other legal authorities to prevent or control disease, injury, or disability or for other health oversight activities authorized by law, such as reporting reactions to medications or problems with products and notifying people of recalls of products they may be using.
Health Oversight Activities
We may disclose health information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure which are necessary for the government to monitor the health care system, government programs involving health care, and compliance with certain civil rights laws.
Lawsuits and Disputes
We may disclose protected health information in the course of any judicial or administrative proceeding, in response to an order of a court of administrative tribunal (to the extent such disclosure is expressly authorized), in certain conditions in response to subpoena, discovery request or other lawful process.
We may release certain health information if asked to do so by a law enforcement official to assist such official in carrying out his or her duties, including such things as identifying or locating a suspect, fugitive, material witness, or missing person or reporting a crime, the location of the crime or victims, or the identity, description or location of the person who committed the crime.
Coroner, Medical Examiners and Funeral Directors
We may release health information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also release health information about patients to funeral directors as necessary for them to carry out their duties. We may disclose such information in reasonable anticipation of death. Protected health information may be used and disclosed for cadaveric organ, eye or tissue donation purposes.
We may release health information about you to authorized federal officials for government functions such as special investigations, intelligence, counterintelligence, and other national security activities authorized by law, including disclosures necessary for the protection of the President and other authorized individuals.
Inmates/Persons in Custody. If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release health information about you to the correctional institution or law enforcement official as necessary to allow them to carry out certain specified activities, including, but not limited to providing you with health care, protecting the health and safety of you and others, and protecting the security of the correctional institution.
Other Uses of Health Information
Other uses and disclosures of health information not covered by this notice or the laws that apply to us will be made only with your written authorization. You may revoke this authorization at any time in writing, except to the extent that action has already been taken in reliance on the use or disclosure permitted by the authorization. If you revoke your authorization, we will no longer use or disclose health information about you for the reasons covered by your written authorization. Of course, we are unable to take back any disclosures we have already made with your permission.
Your Rights Regarding Your Health Information
Right To Inspect and Copy. You have the right to inspect and copy health information that is maintained in a designated record set (which generally includes medical and billing records), with a few exceptions. To inspect and copy such information, you must complete the form provided by our office. If you request a copy of the information, we may charge a fee for the costs of copying, mailing, or other supplies and services associated with your request. We may require that you pay such fee prior to receiving the requested copies. We may deny your request to inspect and copy in certain circumstances. In some instances, you may request that such denial be reviewed, which review will be conducted by a licensed health care professional chosen by us who had no involvement with the original denial. We will comply with the outcome of the review.
Right To Request Amendment. If you believe that our records contain information that is incorrect or incomplete, you may ask us to amend the information by completing the form provided by us. You have the right to request an amendment for as long as the information is kept by or for this office. We may deny your request for an amendment under certain circumstances. If your request is denied, you will be informed of the reason for the denial and will have an opportunity to submit a statement of disagreement to be maintained with your records.
Right to an Accounting of Disclosures. You have the right to request an “accounting of disclosures.” This is a list of the disclosures we made of health information about you, with certain exceptions specifically defined by law. To request this list or accounting of disclosures you must complete our form, providing information we need to process your request. The first list you request within a 12 month period will be free. For additional lists, we may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at the time before any costs are incurred.
Right to Request Restrictions. You have the right to request a restriction or limitation on the health information we use or disclose about you for treatment, payment, or health care operations. You also have the right to request a limit on the health information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend. We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment. To request restrictions, you must complete a specific form provided by our office.
Right to Request Alternative Methods of Communications. You have the right to request that we communicate with you about confidential matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail. To request an alternative method of communication, you must complete a specific form provided by our office providing information we need to process your request. We will not ask you the reason for your request and will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.
Right to a Paper Copy of This Notice. You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice. In order to obtain a paper copy of this notice, please contact us at the phone number or address set forth below.
If you are concerned that your privacy rights may have been violated, or if you disagree with a decision we made about access to your health information, you may file a complaint with the HIPAA Privacy Official at the above address or by phone at 316-682-7546.
You also have the right to file a complaint with the Secretary of the Department of Health and Human Services. Send your complaint to: Medical Privacy, Complaint Division, Office for Civil Rights, United States Department of Health and Human Services 200 Independence Avenue, SW, Room 509F, HHH Building Washington DC, 20201 or contact the Voice Hotline Number at (800) 368- 1019; or send the information to their internet address. We will not take retaliatory action against you if you file a complaint about our privacy practices to us or with the Office for Civil Rights or any other governmental agency.
Changes to this Notice
We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for health information we already have about you as well as any information we receive in the future. We will post a copy of the current notice in the Covered Entity. The notice will contain on the first page the effective date.
You will be asked to provide a written acknowledgement of your receipt of this Notice of Privacy Practices. We are required by law to make a good faith effort to provide you with our Notice of Privacy Practices and obtain such acknowledgement from you. However, your receipt of care and treatment from us is not conditioned upon your providing the written acknowledgement.
Derby Derm recognizes that respecting user privacy over the Internet is of utmost importance. This privacy statement is designed to provide information about the privacy and data collection practices for the site: http://www.derbyderm.com. The site is operated by Derby Derm.
If you have questions or concerns regarding this statement, you should first contact our site coordinator at email@example.com or by postal mail to:
Identifying Information. In general, you can visit the site without telling us who you are or providing any information about yourself. In some areas of the site, we ask you to provide information that will enable us to process an order, offer services that require registration, assist you with technical support issues or to follow up with you. Generally, Derby Derm, requests identifying information when you:
In these instances, Derby Derm will ask for your name, address, e-mail address, phone number and other appropriate information needed to provide you with these services. In all instances, if you receive a newsletter or other mailing from us, you will always be able to “unsubscribe” to these mailings at any time.
What Derby Derm Will Do With Your Information. If you choose to give us personal information for any of the purposes above, this information is retained by Derby Derm and will only be used by Derby Derm to support your customer relationship with us. We will not add you to a mailing list, or newsletter without your registration for this service. We will only contact you if further information is required from you to complete a service.
What Others May Do With Your Information. Derby Derm does not share, rent, or sell any personally identifying information provided through our Site (such as your name or email address) to any outside organization for use in its marketing or solicitations. From time to time Derby Derm may use agents or contractors who will have access to your personal information to perform services for Derby Derm (such as DATABASE MAINTENANCE, FURTHER EXAMPLES), however, they are required by us to keep the information confidential and may not use it for any purpose other than to carry out the services for Derby Derm . In addition, Derby Derm may also share aggregate information about its customers and its web site visitors to advertisers, business partners, and other third parties. For example, we might share that our users are x percent PCs users and y percent Macintosh users. None of this information, however, will contain personal, identifying information about our users.
Third Party Links
Derby Derm.com does provide links to other sites. Other Internet sites and services have separate privacy and data collection practices. Once you leave WWW.Derby Derm.COM, Derby Derm cannot control, and has no responsibility for, the privacy policies or data collection activities at another site.
Children’s Privacy Protection
Derby Derm is sensitive to the heightened need to protect the privacy of children under the age of 13. The vast majority of the material on our web site is not intended for children and is not targeted to children under the age of 13. We do not knowingly collect data from children and, if we learn that we have received personal data from a child, we will remove this information from our database.
Changes to this Policy
Credit Card Security
We know customers are concerned about credit card security. We use one of the worlds largest funds transfer agencies – PayPal.
If you choose to use a PayPal account, your personal credit card information will not be given to Derby Derm.