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Welcome to Bergen Dermatology Specialists

We look forward to seeing you for your visit.

Please fill out the electronic form below.
If you don’t want to fill out this form electronically, click here to print a PDF version and fill it out prior to your appointment.
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    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


    I am a parent/legal guardian of   

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