Private Information – Psychiatrist Available for Medication Management

Step 1 of 6 - Demographic Information

First Name

Last Name

SSN

DOB

Address

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Emergency Contact Name

Phone

Address

Pharmacy Name

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Therapist Name

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Primary Physician Name

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Patient Signature

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Gurdian Signature

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PATIENT FINANCIAL AGREEMENT

The following information is provided to all patients, new and established, to inform patients of our office financial policies and patient financial responsibilities and requirements. Please ask one of our team members if you have any questions regarding these policies.

Hylermed is committed to serving our patients with professionalism and caring, and from our patients we expect the same commitment. This includes being on time for your appointment and calling to cancel an appointment if you can’t make it. It also includes financial responsibilities, providing your current and accurate identification, and making your payments at the time of your office visit with a credit card such as Visa and Mastercard Card. Your credit card information is kept on file for current and future payments. Please notify us if your credit card information is changed.

Self-Pay Patients: The payment is due at the time of service. The amount you pay for the day of scheduled office visit may not be your final payment. Other costs that may be accrued for the appointment include, but not limited to, injections, special procedures, or administrative documents charges. These services are administered only with your consent.

Lyra Patients: We require an active credit card for payment on file. If Lyra does not pay for your services within 2 weeks, we’ll notify you of the unpayment and charge your credit card. If we receive the payment from Lyra It will be refunded to you. Other costs that may be accrued for the appointment include, but are not limited to, injections, special procedures, or administrative documents charges will be charged directly to you. These services are administered only with your consent.

Administrative Charges: Any additional paperwork requests outside of your appointment will be charged based on each request.

Laboratory Bills: Any laboratory procedures that are ordered during today's visit will be billed to you directly by the laboratory. Please contact you rlaboratory directly for any question regarding yourlab bill.

Missed Appointments: Please note a $100.00 cancellation fee will apply for missed appointments or failure to cancel 1 business day prior to yours cheduled appointment date.If you miss three appointments within 12 months period, we may dis-enroll you from our office. Please help us to serve you better by keeping your regularly scheduled appointment.

Payment Enforcement: It is necessary to strictly enforce the policy of financial obligation. We would ask that you pay your balance within 30 days following your invoice date. Accounts that are 90days past due are subject to being sent to a collection agency or small claims court for the unpaid bills.

I have read and understand entire the above statements. I agree to comply with the financial policies of the office, and I am financially responsible for my account.

Patient or Guardian Signature:

Date

AUTHORIZATION FOR CREDIT CARD PAYMENT(S)

Patient’s Name:

Type of Card:
Visa
Mastercard

Credit Card Number:

Cardholder Name:

Expiration Date:
MM slash DD slash YYYY

Security Code:

Cardholder Billing Address:

Cardholder Phone Number:

Cardholder Email Address:

I authorize Hylermed to charge the following:
Office Visits and related charges
Pay for all Expenses that not covered by patient.
Specific payment(s)

on date
MM slash DD slash YYYY

Cardholder Authorized Signature:

Date
MM slash DD slash YYYY

Patient or Guardian Signature:

Date
MM slash DD slash YYYY

ACKNOWLEDGEMENT OF NOTICE OF PRIVACY PRACTICE
At Hylermed, we understand the importance of privacy and are committed to maintaining the confidentiality of your personal health information. We are required by law to maintain the privacy of protected health information and provide you our Privacy Practice Notice. The Privacy Practice Notice is posted in our office where it can be viewed by staff, patients, and guests.

By signing below, you acknowledge that you have received Hylermed’s Notice of Privacy Practice.

I understand that it is my responsibility to read and understand Hylermed’s Notice of Privacy Practice. I further understand that I should consult Hylermed’s privacy officer regarding any questions I may have.
Patient or Guardian Signature:
Date
MM slash DD slash YYYY

NOTICE OF PRIVACY PRACTICE 9404 Genesee Ave. Suite 245, La Jolla, CA 92037 619-707-1554
This notice describes how health information about you may be used and disclosed and how you can get access to this information. Please review it carefully.
We understand the importance of privacy and are committed to maintaining the confidentiality of your medical information. We make a record of the health care we provide and may receive such records from others. We use these records to provide or enable other health care providers to provide quality medical care, to obtain payment for services provided to you as allowed by your health plan and to enable us to meet our professional and legal obligations to operate this treatment center properly. We are required by law to maintain the privacy of protected health information, to provide individuals with notice of our legal duties and privacy practices with respect to protected health in- formation, and to notify affected individuals following a breach of unsecured protected health information. This notice describes how we may use and disclose your medical information. It also describes your rights and our legal obligations with respect to your medical information. If you have any questions about this Notice, please contact our Privacy Officer listed above.

A. How Hylermed May Use or Disclose Your Health Information
The health record is the property of this medical practice, but the information in the health record belongs to you. The law permits us to use or disclose your health information for the following purposes:

1. Treatment. We use health information about you to provide your medical care. We disclose health information to our employees and others who are involved in providing the care you need. For example, we may share your health information with other physicians or other health care providers who will provide services that we do not provide or we may share this information with a pharmacist who needs it to dispense a prescription to you, or a laboratory that performs a test. We may also disclose health information to members of your family or others who can help you when you are sick or injured or following your death.

2. Payment. We use and disclose health information about you to obtain payment for the services we provide. For example, we give your health plan the information it requires for payment. We may also disclose information to other health care providers to assist them in obtaining payment for services they have provided to you.

3. Health Care Operations. We may use and disclose health information about you to operate this treatment center. For example, we may use and disclose this information to review and improve the quality of care we provide, or the competence and qualifications so four professional staff. Or we may use and disclose this information to get your health plan to authorize services or referrals. We may also use and disclose this information as necessary for health reviews, legal services and audits, including fraud and abuse detection and compliance programs and business planning and management. We may also share your health information with our “business associates,” such as our billing service, that perform administrative services for us. We have a written contract with each of these business associates that contains terms requiring them and their subcontractors to protect the confidentiality and security of your health information. Although federal law does not protect health information which is disclosed to someone other than another healthcare provider, health plan, healthcare clearinghouse or one of their business associates, California law prohibits all recipients of healthcare information from further disclosing it except as specifically required or permitted by law. We may also share your information with other health care providers, health care clearinghouses or health plans that have a relationship with you, when they request this information to help them with their quality assessment and improvement activities, their patient-safety activities, their population-based efforts to improve health or reduce health care costs, protocol development, case management or care coordination activities, their review of competence, qualifications and performance of health care professionals, their training programs, their accreditation, certification or licensing activities, their activities related to contracts of health insurance or health benefits, or their health care fraud and abuse detection and compliance efforts.

4. Appointment Reminders. We may use and disclose health information to contact and remind you about appointments. If you are not home, we may leave this information on your answering machine or in a message left with the person answering the phone.

5. Sign-in Sheet. We may use and disclose health information about you by having you sign in when you arrive at our office. We may also call out your name when we are ready to see you.

6. Notification and Communication with Family. We may dis- close your health information to notify or assist in notifying a family member, your personal representative or another person responsible for your care about your location, your general condition or, unless you had instructed us otherwise, in the event of your death. In the event of a disaster, we may disclose information to a relief organization so that they may coordinate these notification efforts. We may also disclose information to someone who is involved with your care or helps pay for your care. If you are able and available to agree or object, we will give you the opportunity to object prior to making these disclosures, although we may disclose this information in a disaster even over your objection if we believe it is necessary to respond to the emergency circumstances. If you are unable or unavailable to agree or object, our health professionals will use their best judgment in communication with your family and others.

7. Marketing. Provided we do not receive any payment for making these communications, we may contact you to encourage you to purchase or use products or services related to your treatment, case management or care coordination, or to direct or recommend other treatments, therapies, health care providers or settings of care that may be of interest to you. We may similarly describe products or services provided by this practice and tell you which health plans we participate in. We may receive financial compensation to talk with you face-to-face, to provide you with small promotional gifts, or to cover our cost of reminding you to take and refill your medication or otherwise communicate about a drug or biologic that is currently prescribed for you, but only if you either: (1) have a chronic and seriously debilitating or life-threatening condition and the communication is made to educate or advise you about treatment options and otherwise maintain adherence to a pre- scribed course of treatment, or (2) you are a current health plan enrollee, and the communication is limited to the availability of more cost effective pharmaceuticals. If we make these communications while you have a chronic and seriously debilitating or life threatening condition, we will provide notice of the following in at least 14-point type: (1) the fact and source of the remuneration; and (2) your right to opt-out of future remunerated communications by calling the communicator’s toll-free number. We will not otherwise use or disclose your medical information for marketing purposes or accept any payment for other marketing communications without your prior written authorization. The authorization will disclose whether we receive any financial compensation for any marketing activity you authorize, and we will stop any future marketing activity to the extent you revoke that authorization.

8. Sale of Health Information. We will not sell your health information without your prior written authorization. The authorization will disclose that we will receive compensation for your health information if you authorize us to sell it, and we will stop any future sales of your information to the extent that you revoke that authorization.

9. Required by Law. As required by law, we will use and disclose your health information, but we will limit our use or disclosure to the relevant requirements of the law. When the law requires us to report abuse, neglect or domestic violence, or respond to judicial or administrative proceedings, or to law enforcement officials, we will further comply with the requirement set forth below concerning those activities.

10. Public Health. We may, and are sometimes required by law to, disclose your health information to public health authorities for purposes related to: preventing or controlling disease, injury or disability; reporting child, elder or dependent adult abuse or neglect; reporting domestic violence; reporting to the Food and Drug Administration problems with products and reactions to medications; and reporting disease or infection exposure. When we report suspected elder or dependent adult abuse or domestic violence, we will inform you or your per- sonal representative promptly unless in our best professional judgment, we believe the notification would place you at risk of serious harm or would require informing a personal representative we believe is responsible for the abuse or harm.

11. Health Oversight Activities. We may, and are sometimes required by law, to disclose your health information to health oversight agencies during the course of audits, investigations, inspections, licensure and other proceedings, subject to the limitations imposed by federal and California law.

12. Judicial and Administrative Proceedings. We may, and are sometimes required by law, to disclose your health information in the course of any administrative or judicial proceeding to the extent expressly authorized by a court or administrative order. We may also disclose information about you in response to a subpoena, discovery request or other lawful process if reasonable efforts have been made to notify you of the request and you have not objected, or if your objections have been resolved by a court or administrative order.

Law Enforcement. We may, and are sometimes required by law, to disclose your health information to a law enforcement official for purposes such as identifying of locating a suspect, fugitive, material witness or missing person, complying with a court order, warrant, grand jury subpoena and other law enforcement purposes.

13. Coroners. We may, and are often required by law, to disclose your health information to coroners in connection with their investigations of deaths.

14. Organ or Tissue Donation. We may disclose your health information to organizations involved in procuring, banking or transplanting organs and tissues.

15. Public Safety. We may, and are sometimes required by law, to disclose your health information to appropriate persons in order to prevent or lessen a serious and imminent threat to the health or safety of a particular person or the general public.

16. Proof of Immunization. We will disclose proof of immunization to a school where the law requires the school to have such information prior to admitting a student if you have agreed to the disclosure on behalf of yourself or your dependent.

Specialized Government Functions. We may disclose your health information for military or national security purposes or to correctional institutions or law enforcement officers that have you in their lawful custody.

17. Worker’s Compensation. We may disclose your health information as necessary to comply with worker’s compensation laws. For example, to the extent your care is covered by workers’ compensation, we will make periodic reports to your employer about your condition. We are also required by law to report cases of occupational injury or occupational illness to the employer or workers’ compensation insurer.

18. Change of Ownership. In the event that this treatment center is sold or merged with another organization, your health information/record will become the property of the new owner, although you will maintain the right to request that copies of your health information be transferred to another physician or medical group.

21. Breach Notification. In the case of a breach of unsecured protected health information, we will notify you as required by law. If you have provided us with a current email address, we may use email to communicate information related to the breach. In some circumstances our business associate may pro- vide the notification. We may also provide notification by other methods as appropriate.

22. Research. We may disclose your health information to researchers conducting research with respect to which your written authorization is not required as approved by an Institutional Review Board or privacy board, in compliance with governing law.

B. When Hylermed May Not Use or Disclose Your Health Information
Except as described in this Notice of Privacy Practices, this treatment center will, consistent with its legal obligations, not use or disclose health information which identifies you without your written authorization. If you do authorize this medical practice to use or disclose your health information for another purpose, you may revoke your authorization in writing at any time.

C. Your Health Information Rights
Right to Request Special Privacy Protections. You have the right to request restrictions on certain uses and disclosures of your health information by a written request specifying what information you want to limit, and what limitations on our use or disclosure of that information you wish to have imposed. If you tell us not to disclose information to your commercial health plan concerning health care items or services for which you paid for in full out-of-pocket, we will abide by your re- quest, unless we must disclose the information for treatment or legal reasons. We reserve the right to accept or reject any other request, and will notify you of our decision.

1. Right to Request Confidential Communications. You have the right to request that you receive your health information in a specific way or at a specific location. For example, you may ask that we send information to a particular email account or to your work address. We will comply with all reasonable requests submitted in writing which specify how or where you wish to receive these communications.

2. Right to Inspect and Copy. You have the right to inspect and copy your health information, with limited exceptions. To access your medical information, you must submit a written request detailing what information you want access to, whether you want to inspect it or get a copy of it, and if you want a copy, your preferred form and format. We will provide copies in your requested form and format if it is readily producible, or we will provide you with an alternative format you find acceptable, or if we can’t agree and we maintain the record in an electronic format, your choice of a readable electronic or hardcopy format. We will also send a copy to any other person you designate in writing. We will charge a reasonable fee which covers our costs for labor, supplies, postage, and if requested and agreed to in advance, the cost of preparing an explanation or summary, as allowed by federal and California law. We may deny your request under limited circumstances. If we deny your request to access your child’s records or the records of an incapacitated adult you are representing because we believe allowing access would be reasonably likely to cause substantial harm to the patient, you will have a right to appeal our decision. If we deny your request to access your psychotherapy notes, you will have the right to have them transferred to another mental health professional.

3. Right to Amend or Supplement. You have a right to request that we amend your health information that you believe is incorrect or incomplete. You must make a request to amend in writing, and include the reasons you believe the information is inaccurate or incomplete. We are not required to change your health information, and will provide you with information about this medical practice’s denial and how you can disagree with the denial. We may deny your request if we do not have the information, if we did not create the information (unless the person or entity that created the information is no longer avail- able to make the amendment), if you would not be permitted to inspect or copy the information at issue, or if the information is accurate and complete as is. If we deny your request, you may submit a written statement of your disagreement with that decision, and we may, in turn, prepare a written rebuttal. You also have the right to request that we add to your record a statement of up to 250 words concerning anything in the record you believe to be incomplete or incorrect. All information related to any request to amend or supplement will be maintained and disclosed in conjunction with any subsequent disclosure of the disputed information.

4. Right to an Accounting of Disclosures. You have a right to receive an accounting of disclosures of your health information made by this medical practice, except that this medical practice does not have to account for the disclosures provided to you or pursuant to your written authorization, or as described in paragraphs 1 (treatment), 2 (payment), 3 (health care operations) 6 (notification and communication with family) and 18 (specialized government functions) of Section A of this Notice of Privacy Practices or disclosures for purposes of research or public health which exclude direct patient identifiers, or which are incident to a use or disclosure otherwise permitted or authorized by law, or the disclosures to a health oversight agency or law enforcement official to the extent this medical practice has received notice from that agency or official that providing this accounting would be reasonably likely to impede their activities.

5. You have a right to notice of our legal duties and privacy practices with respect to your health information, including a right to a paper copy of this Notice of Privacy Practices, even if you have previously requested its receipt by e-mail. If you would like to have a more detailed explanation of these rights or if you would like to exercise one or more of these rights, contact our Privacy Officer listed at the top of this Notice of Privacy Practices.
C. Changes to this Notice of Privacy Practices
We reserve the right to amend our privacy practices and the terms of this Notice of Privacy Practices at any time in the future. Until such amendment is made, we are required by law to comply with this Notice. After an amendment is made, the revised Notice of Privacy Protections will apply to all protected health information that we maintain, regardless of when it was created or received. We will keep a copy of the current notice posted in our reception area, and a copy will be available at each appointment. We will also post the current notice on our website
D. Complaints
Complaints about this Notice of Privacy Practices or how this medical practice handles your health information should be directed to our Privacy Officer listed at the top of this Notice of Privacy Practices.

If you are not satisfied with the manner in which this office handles a complaint, you may submit a formal complaint to:

Region IX - Office of Civil Rights
U.S. Department of Health & Human Services 90 7th Street, Suite 4-100
San Francisco, CA 94103
(415) 437-8310; (415) 437-8311 (TDD)
(415) 437-8329 (fax)
OCRMail@hhs.gov

The complaint form may be found at www.hhs.gov/ocr/privacy/ hipaa/complaints/hipcomplaint.pdf. You will not be penalized in any way for filing a complaint.