NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU
MAY BE USED, DISCLOSED AND SAFEGUARDED, AND HOW YOU CAN
GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT
CAREFULLY.
I. Who is Subject to This Notice
Daniel Gardner, MD, A Professional Corporation
II. Our Responsibility
The confidentiality of your personal health information is
very important to us. Your health information includes
records that we create and obtain when we provide you
care, such as a record of your symptoms, examination and
test results, diagnoses, treatments and referrals for
further care. It also includes bills, insurance claims,
or other payment information that we maintain related to
your care.
This Notice describes how we handle your health
information and your rights regarding this information.
Generally speaking, we are required to:
- Maintain the privacy of your health information as
required by law;
- Provide you with this Notice of our duties and
privacy practices regarding the health information about
you that we collect and maintain;
- Follow the terms of our Notice currently in effect.
III. Contact Information
After reviewing this Notice, if you need further
information or want to contact us for any reason regarding
the handling of your health information, please direct any
communications to the following contact person:
Daniel Gardner, MD
Suite 214
4550 Kearny Villa Road
San Diego, CA 92123
dgardner@ucsd.edu
IV. Uses and Disclosures of Information
Under federal law, we are permitted to use and disclose
personal health information without authorization for
treatment, payment, and health care operations. However,
the American Psychiatric Association?s Principles of
Medical Ethics or state law may require us to obtain your
express consent before we make certain disclosures of your
personal health information.
Example of using or disclosing health information for
treatment:
- A nurse takes your pulse and blood pressure,
records it in the medical record, and informs your doctor
of the results.
Example of using or disclosing health information for
payment:
- We submit a bill to your health insurer to receive
payment for your care; the insurer asks for health
information (for example, your diagnosis and what care we
provided) in order to pay us. In such situations, we will
disclose only the minimum amount of information necessary
for this purpose.
V. Other Uses and Disclosures
Required By Law
- We may disclose health information about you as
required by federal, state, or other applicable law.
Workers? Compensation
- We may disclose health information about you for
purposes related to workers? compensation, as required and
authorized by law.
Any Other Use or Disclosure -- Authorization Required
- Before using or disclosing your personal health
information for any other purpose not identified above, we
will obtain your written authorization. Unless action has
already been taken in reliance on the authorization, you
have a right to revoke such authorization by submitting
your request in writing to us (see section III above for
contact information).
VI. Psychotherapy Notes
Psychotherapy notes may be disclosed by a therapist only
after you have given written authorization to do so.
(Limited exceptions exist, e.g. in order for your
therapist to prevent harm to yourself or others, and to
report child abuse/neglect). You cannot be required to
authorize the release of your psychotherapy notes in order
to obtain health-insurance benefits for your treatment, or
enroll in a health plan. Psychotherapy notes are also not
among the records that you may request to review or copy
(see discussion of your rights in section VII below). If
you have any questions, feel free to discuss this subject
with Dr. Gardner
VII. Your Health Information Rights
Under the law, you have certain rights regarding the
health information that we collect and maintain about
you. This includes the right to:
- Request that we restrict certain uses and
disclosures of your health information; we are not,
however, required to agree to a requested restriction.
- Request that we communicate with you by
alternative means, such as making records available for
pick-up, or mailing them to you at an alternative address,
such as a P.O. Box. We will accommodate reasonable
requests for such confidential communications.
- Request to review, or to receive a copy of, the
health information about you that is maintained in our
files and the files of our business associates (if
applicable). If we are unable to satisfy your request, we
will tell you in writing the reason for the denial and
your right, if any, to request a review of the decision.
- Request that we amend the health information about
you that is maintained in our files and the files of our
business associates (if applicable). Your request must
explain why you believe our records about you are
incorrect, or otherwise require amendment. If we are
unable to satisfy your request, we will tell you in
writing the reason for the denial and tell you how you may
contest the decision, including your right to submit a
statement (of reasonable length) disagreeing with the
decision. This statement will be added to your records.
- Request a list of our disclosures of your health
information. This list, known as an ?accounting? of
disclosures, will not include certain disclosures, such as
those made for treatment, payment, or health care
operations. We will provide you the accounting free of
charge. However, if you request more than one accounting
in any 12 month period, we may impose a reasonable, cost-
based fee for any subsequent request. Your request should
indicate the period of time in which you are interested
(for example, ?from May 1, 2003 to June 1, 2003?). We
will be unable to provide you an accounting for any
disclosures made before April 14, 2003, or for a period of
longer than six years
-
- Request a paper copy of this Notice.
In order to exercise any of your rights described above,
you must submit your request in writing to our contact
person (see section III above for information). If you
have questions about your rights, please speak with
Dr.Gardner, available in person or by phone or email,
during normal office hours.
VIII. To Request Information or File a Complaint
If you believe your privacy rights have been violated, you
may file a written complaint by mailing it or delivering
it to Dr. Gardner (see section III above). You may
complain to the Secretary of Health and Human Services
(HHS) by writing to Office for Civil Rights, U.S.
Department of Health and Human Services, 200 Independence
Avenue, S.W., Room 509F, HHH Building, Washington, D.C.
20201; by calling 1-(800) 368-1019; or by sending an email
to OCRprivacy@hhs.gov. We cannot, and will not, make you
waive your right to file a complaint as a condition of
receiving care from us, or penalize you for filing a
complaint
IX. Revisions to this Notice
We reserve the right to amend the terms of this Notice.
If this Notice is revised, the amended terms shall apply
to all health information that we maintain, including
information about you collected or obtained before the
effective date of the revised Notice. If the revisions
reflect a material change to the use and disclosure of
your information, your rights regarding such information,
our legal duties, or other privacy practices described in
the Notice, we will promptly distribute the revised
Notice, post it in the waiting area(s) of our office, and
make copies available to our patients and others.
X. Effective Date: 11/6/03
(Please detach and return this page)
Daniel Gardner, MD
Psychiatry, Psychoanalysis, Neurobehavioral Medicine
Diplomate, American Board of Psychiatry and Neurology
Landmark Center: 4550 Kearny Villa Road, Suite 214, San
Diego, CA 92123
Lomas Santa Fe Plaza: 993¬-E Lomas Santa Fe Drive, Solana
Beach, CA 92075
Phone/Fax: 858-560-5609 Email: dgardner@ucsd.edu
Patient's Acknowledgment of Receipt of
Notice of Privacy Practices
Patient Name: ________________________________________
Birth date: _________
Maiden or other name (if
applicable):_________________________________________
I acknowledge that I have received a copy of the Notice of
Privacy Practices of Daniel Gardner, MD, A Professional
Corporation, effective 11/6/03
Signature (patient or authorized
representative):______________________________
Date: _________________
Relationship/authority (if signed by authorized
representative): ______________________
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