Philadelphia and Mainline Center of Dermatology and Cosmetic Surgery

Cosmetic Consultation

This form must be filled in prior to the in-person consultation. Our certified aestheticians use the information provided to prepare for the consultation and to pre-determine some of their recommendations

Personal information

no nicknames please

Contact information


Skin & hair information

Do you have a special event you are trying to look your best for?

if yes, what is the date?

Do you want to discuss any of the following conditions and treatments?

For women:

  • Privacy policy

      Notice of Privacy Practices

      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

      Effective September 23, 2013


      As a covered entity, as defined under the Health Insurance Portability and Accountability Act (HIPAA) of 1996, as amended, Ringpfeil Advanced Dermatology, PC (the Practice), we are required by law to maintain the privacy of your protected health information. This Notice of Privacy Practices (the Notice) sets forth our obligations and your rights regarding the use and disclosure of your protected health information. Protected health information is individually identifiable health information that the Practice or its business associates maintain or transmit in any form or medium, including verbal conversations and written or electronic information. Individually identifiable health information is information that identifies you, or could reasonably be used to identify you, and that relates to your past, present or future (a) physical or mental health, (b) provision of health care, or (c) payment for such health care.

      The Practice's Duties Regarding This Notice

      The Practice must give you this Notice to explain the uses and disclosures of your protected health information, to advise you of your rights with respect to your protected health information, and to explain the Practice's legal duties and privacy practices with respect to your protected health information under HIPAA and related regulations. The Practice is required to abide by the terms of the Notice currently in effect. The Practice reserves the right to change the terms of this Notice and make the new provisions applicable to all protected health information that it maintains. In the event the Practice changes this Notice in a significant manner, the Practice will distribute a revised notice within 60 days of the effective date of the change. Remember the Practice does not maintain all of your medical information. Your health care plan (e.g., health insurance) also maintains some of your information. You should contact your health plan directly if you have any questions about medical information maintained by them.

      How Your Protected Health Information May Be Used or Disclosed For Treatment, Payment and Health Care Operations

      The confidentiality of your protected health information is very important to us. The Practice is able to use or disclose your protected health information for treatment, payment, and health care operations as explained below. Other uses and disclosures of your protected health information are explained in later sections of this Notice.


      Treatment means the coordination or management of health care and related services by one or more health care providers. For example, the Practice may disclose, for treatment purposes, protected health information to a health care provider such as another physician, hospital, pharmacist or nurse involved in your care.


      The Practice may use and disclose protected health information so that we or others may bill and receive payment from you, an insurance company or a third party for the treatment and services you received. For example, we may give your health plan information about you so that they will pay for your treatment.

      Health Care Operations

      We may use and disclose protected health information for health care operations purposes. These uses and disclosures are necessary to make sure that all of our patients receive quality care and to operate and manage our office. For example, we may use and disclose information to make sure the dermatological care you receive is of the highest quality. We also may share information with other entities that have a relationship with you (for example, your health plan) for their health care operation activities.

      Other Information

      The Practice will take reasonable steps and apply safeguards to limit the permitted or required uses and disclosures of your protected health information to the minimum amount necessary to accomplish the task. The descriptions listed above do not include every possible use or disclosure that is permitted or required by law. The descriptions given are only intended to provide you with information about the various ways that the Practice may use or disclose your protected health information and to give you some examples.

      Other Permitted or Required Uses and Disclosures

      Other than treatment, payment and health care operations, the Practice is permitted or required by law to use or disclose your protected health information in other ways described below.

      Appointment Reminders, Treatment Alternatives and Health Related Benefits and Services

      The Practice also may use your protected health information to contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you.


      Under certain circumstances, we may use and disclose protected health information for research. For example, a research project may involve comparing the health of patients who received one treatment to those who received another for the same condition. Before we use or disclose protected health information for research, the project will go through a special approval process and there are limitations on how your protected health information may be used for research purposes. The Practice may also seek your authorization for the use of PHI for research.

      To You or Certain Other Individuals

      Your own protected health information may be disclosed to you or to your personal representative who is an individual, under applicable law, authorized to make health care decisions on your behalf. For example, a parent is generally the personal representative of a minor child. This Practice may disclose your protected health information to a family member, other relative, close personal friend or other person identified by you. The protected health information that is disclosed must be directly relevant to the family member or other person's involvement with your health care. The requirements are that you must be present or available prior to the use or disclosure and (a) agree, (b) have the opportunity to object or (c) the Practice may determine, based on the circumstances and its professional judgment, to make the disclosure. If you are not present or are incapacitated, the Practice may use its professional judgment to determine whether the disclosure of protected health information is in your best interests. If the Practice makes this determination, it may disclose only your protected health information that is directly relevant to the individual's involvement with your health care. The Practice may, in certain situations, use or disclose your protected health information to notify, or assist in notifying, a family member, personal representative or other person involved in your care of your location or condition. If you do not want this information to be shared, you may request that these disclosures be restricted as outlined later in this Notice.

      To Business Associates

      The Practice works with different organizations that perform a variety of services on its behalf. The organizations, or Business Associates, perform specific functions and services for the Practice. For example, we may use another company to perform billing services on our behalf. Services also include consulting, legal, financial, and management activities. The Practice may disclose protected health information to its Business Associates for the permitted functions or services, but only if the Practice receives assurances through a written contract or agreement that the Business Associate will properly safeguard the information.

      In A Limited Data Set

      A limited data set contains protected health information from which direct identifiers such as name and social security number have been removed, but indirect identifiers such as date of service have been kept. Information in a limited data set may be used or disclosed for research, public health or health care operations. The information may be disclosed only if the Practice has entered into an agreement with the recipient that establishes its permitted uses or disclosures.

      As Required by Law and for Public Benefit

      Protected health information may be:

      • Used or disclosed as required by law and in compliance with the requirements of the law, including disclosures to the Secretary of Health and Human Services for the purpose of determining compliance with the privacy standards;
      • Disclosed to an authorized public health authority for specified reasons such as to prevent or control disease, injury, or disability; to report child abuse or neglect; to report the safety or effectiveness of FDA-related products such as medication; and to notify a person at risk of contracting or spreading a communicable disease;
      • Disclosed to an authorized government authority if the disclosure is about victims of abuse, neglect, or domestic violence;
      • Disclosed to authorized health oversight agencies for activities such as audits, investigations, inspections, and licensure requirements necessary for oversight of the health care system and various government benefit programs;
      • Disclosed for judicial and administrative proceedings such as responses to court orders and court-ordered warrants, to subpoenas issued, to discovery requests, or other lawful processes;
      • Disclosed to a law enforcement official for a law enforcement purpose;
      • Disclosed to federal officials for national security reasons;
      • Disclosed to coroners or medical examiners for purposes of identifying a deceased individual and to funeral directors to carry out their duties;
      • Used or disclosed to an organ and tissue procuring or transplant organization to facilitate donation transplantation;
      • Used or disclosed for research purposes if certain requirements are met;
      • Used or disclosed as necessary to prevent or lessen a serious or imminent threat to the health and safety of person or the public;
      • Disclosed to comply with workers' compensation or other similar laws;
      • Disclosed to comply with laws related to military service or veterans affairs; and
      • Disclosed to a public or private entity authorized by law or by its charter to assist in disaster relief efforts.

      In most situations, reasonable measures will be taken to limit the use and disclosure of protected health information to the individuals who need it and to the amount necessary to perform a particular function.

      Other Uses and Disclosures Only in Accordance with Your Authorization

      Other than the uses or disclosures of your protected health information that are permitted or required by law, the Practice may not use or disclose your protected health information unless you authorize the Practice to do so by completing a written authorization. As a result, uses and disclosures of protected health information for marketing purposes and disclosures that constitute a sale of protected health information will be made only with your express written authorization. Please note that the Practice does not use your protected health information for marketing or fundraising purposes. You may revoke your authorization at any time to stop future uses or disclosures; however, the revocation will not apply to the extent that the Practice has already made uses or disclosures in reliance on your authorization. Your revocation will also not be effective to the extent that the authorization was given as a condition of obtaining insurance coverage if another law gives the insurer the right to contest a claim under the policy or the right to contest the policy itself. Once your protected health information has been disclosed pursuant to your authorization, the privacy protections under HIPAA may no longer apply to the disclosed health information and that information may be re-disclosed by the recipient without your or the Practices knowledge or authorization.

      Your Individual Rights Regarding Your Protected Health Information

      You have certain rights with respect to your protected health information, as described in detail below. You may exercise your rights by submitting a written request that specifies the right(s) you wish to exercise. Requests should be sent to the Human Resources Department. Contact information is provided at the end of this Notice.

      Right to Request Restrictions

      You have the right to request restrictions on certain uses or disclosures of your protected health information for the purposes of treatment, payment or health care operations. The Practice is not required to agree to any restriction that you request. You will be notified if your request is accepted or denied. The Practice may agree to appropriate restrictions if your protected health information pertains to health care items or services that you paid for entirely out-of-pocket and the disclosure of protected health information is for purposes of payment or health care operations.

      Right to Receive Confidential Communications

      You have the right to request receipt of confidential communications of your protected health information from the Practice by reasonable alternative means or at an alternative location. For example, you may not want messages left on voicemail or sent to a particular address. To request confidential communications by alternative means or at an alternative location, you must submit your request in writing with the reason(s) for the request. If appropriate, your request should state that the disclosure of all or part of your protected health information by non-confidential communications could endanger you. The Practice will accommodate reasonable requests and will notify you appropriately.

      Right to Inspect and Copy

      • You have the right to inspect and copy your protected health information that is contained in a designated record set that is, enrollment, payment, claims determination, case or medical management records or records that are used to make decisions about you and that are maintained by the Practice, in a form and format that you request, to the extent such form and format is readily producible by the Practice. The Practice may charge you a reasonable cost-based fee for the labor, supplies and postage associated with your request. There are some exceptions to your right to inspect and copy, such as:
      • Psychotherapy notes (if any),
      • Information compiled in anticipation of a civil, criminal, or administrative action or proceeding, and
      • Situations in which a licensed health care professional determines that releasing the information may have a harmful effect on you or another individual.

      In certain circumstances, if you are denied access to your protected health information, you may request a review of the denial. You may request that the Practice send a copy of your protected health information directly to a designated person.

      Right to Request an Amendment

      If you believe that protected health information about you that is contained in a designated record set is inaccurate or incomplete, you have the right to request that it be amended. Your request must be in writing and you must provide a reason to support your request.

      The Practice may deny your request for an amendment if your request is not in writing or if you do not provide a reason for your request. Your request will also be denied if the Practice determines:

      • The information was not created by the Practice (unless you provide a reasonable basis to believe that the originator of the information is no longer available to act on your request),
      • The information is not maintained by or for the Practice or is not part of the information which you would be permitted to inspect and copy,
      • Access to the information is restricted by law, or
      • The information is accurate and complete.

      If your request is denied, you will receive written notification of the denial explaining the basis for the denial and a description of your rights.

      Right to an Accounting of Disclosures

      You have the right to receive a listing of, or an accounting of, disclosures of your protected health information made by the Practice. Certain disclosures do not have to be included in this accounting, including the following:

      • Those made for treatment, payment or health care operations,
      • Those made pursuant to your written authorization,
      • Those made to you,
      • Those that are incidental to otherwise permitted or required disclosures,
      • Those made as part of a limited data set,
      • Disclosures to individuals involved in your care, and
      • Disclosures for certain security or intelligence reasons and to certain law enforcement officials.

      If you request an accounting of disclosures of your protected health information, you will need to specify the dates you want the accounting to cover. The accounting period cannot exceed six years prior to the date of the request. You are entitled to one free accounting in any 12-month period. The Practice may charge for any additional accountings you request within the same 12-month period. The Practice will notify you in advance of any changes.

      Right to Receive Notification of a Breach

      You have the right to receive a notification from the Practice if there is a breach of your unsecured protected health information.

      Right to Receive a Paper Copy

      Even if you have agreed to receive this Notice electronically, you have the right to request and receive a paper copy of this Notice from the Practice.

      Complaints and Contact Information


      If you are concerned that your privacy rights have been violated, you may submit a complaint to the Practice by contacting Baruch Katz. The complaint must be in writing and provide a description of why you think your privacy rights were violated. No retaliatory actions will be taken against you for filing a complaint.

      You may also file a complaint with the Secretary of Health and Human Services:

      Web site:


      Address: Region III, Office for Civil Rights,
      150 S. Independence Mall W, Suite 372,
      Public Ledger Building
      Philadelphia, PA 19106-9111

      Contact Information

      Please contact Ringpfeil Advanced Dermatology in order to:

      • Obtain a paper copy or another copy of this Notice,
      • Ask questions about this Notice or the Practice's practices regarding protected health information,
      • File a complaint,
      • Request that disclosure of eligibility status or claim status not be provided to a family member,
      • Obtain an Authorization Form, or
      • Make a request for individual rights as described above.

      The phone number is: 610.525.5250

      The address is: Ringpfeil Advanced Dermatology
      569 W Lancaster Ave
      Haverford, PA 19041

Customer Rating : 4.6

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