Privacy Practices & Office Policies

San Diego Family Dermatology (SDFD) is required by law to maintain the privacy of your protected health information and to provide you with notice of our legal duties and privacy practices with respect to your protected health information. This information consists of all records related to your health, including demographic information, either created by San Diego Family Dermatology or received by San Diego Family Dermatology from other healthcare providers. An extended version of our policies is available to you in the purple binders in the waiting room.

Uses and disclosures of your protected health information not requiring your consent:

San Diego Family Dermatology may use and disclose your protected health information, without your written consent or authorization, for certain treatment, payment and healthcare purposes. These include, but are not limited to:

Providing, coordinating, or managing healthcare and related services by one or more healthcare providers
Referrals to other providers or health agencies for treatment
Activities undertaken by San Diego Family Dermatology to obtain reimbursement for services provided to you
Contacting healthcare providers and patients with information about treatment alternatives
Protocol development, case management, or care coordination.
When required by law, for example reporting abuse, neglect, domestic violence, or injuries believed to occur as the result of a crime.
For public health reasons. We are required to report certain infectious diseases to public health authorities.
Workers compensation: we may disclose your health information to insurance or government agencies.

It is our practice to use your information to contact you with appointment reminders. You must notify us if you do not wish to receive appointment reminders or contact in regards to certain treatment alternatives and services.

You have the right to examine your own health record within 3 working days of our receipt of your written request. You have the right to obtain a copy of your own health record within 7 working days of our receipt of your written request and payment. You also have the right to request corrections in your medical record. We may not disclose your protected health information to family members or friends who may be involved with your care without your written permission. Health information may be released without written permission to a parent, guardian, or legal custodian of a child, guardian of an incompetent adult, the healthcare agent designated power of attorney for an incapacitated patient, or the representative or spouse of a deceased patient.

By signing below and giving us your email, you allow us to provide you with access to your electronic Patient Health Record.

PROVIDE PATIENT'S INFO BELOW (if pt is a minor, provide info of parent/guardian)

Name*

First NameLast Name

Date of Birth:*

Date

Sex Assigned at Birth*

MaleFemale

Gender

Social Security Number

Name of Minor/Patient, if not responsible party

First NameLast Name

Date of Birth of Minor/Patient, if not responsible party

Date

TRICARE PATIENTS ONLY, please provide 1) SPONSOR's name, 2) date of birth, and 3) complete social security number / benefit number below.

1) Sponsor's Full Name

First NameLast Name

2) Sponsor's Date of Birth

Date

3) Sponsor's Complete Social / Benefit Number

CONTACT INFORMATION

Mobile Phone Number

Home Phone Number

Work Phone Number

E mail address (By providing an email, you are consenting to receive appointment reminders and may be contacted by staff. Please note that our email is not encrypted.)

example@example.com

Address

Mailing address

Street Address Line 2

CityState

Zip

Best place to leave a message, including CONFIDENTIAL information

Mobile phoneHome phoneWork phoneEmail (please note that email is not encrypted and a signed medical release form is required to provide any portion of your medical record by email or any other format)US Mail

Emergency Contact Information

Name

First NameLast Name

Phone Number

Relationship

CONSENT TO RECEIVE TEXT MESSAGE, EMAIL & VOICE CORRESPONDENCE

I expressly consent and agree that San Diego Family Dermatology may send periodic electronic communications for appointment confirmations and other routine business purposes, at any email address or phone number I provide. Messages may be sent by text (SMS), email, automatic telephone dialing systems (auto-dialer), prerecorded messages or live operator calls. Message frequency will vary. Message and data rates apply. I may opt out of receiving further automated, electronic communications at any time by calling 619-267-8303 or 619-579-5115, texting STOP to 855-487-1609, or emailing info@sdfamilyderm.com. I further understand that SDFD's email system is NOT ENCRYPTED and will notify SDFD if I do not wish to communicate via email.

PHARMACY CONSENT

I expressly consent and agree that SDFD may access my prescribed medications from my pharmacies. I may revoke this consent at any time by notifying SDFD.

CONSENT TO RELEASE INFORMATION

I hereby consent to the release of Protected Health Information to the following individuals. This means I am allowing SDFD to share my medical information with the people I have named below. These individuals may also bring my child, children, or adults for appointments. I understand this authorization will be in effect until which time it is revoked.

Name 1

First NameLast Name

Relationship 1

Name 2

First NameLast Name

Relationship 2

Name 3

First NameLast Name

Relationship 3

With my signature below, I hereby acknowledge that I have read and understand this Notice of Privacy Practicies & Policies in its entirety.

Patient Signature (or parent/guardian, if minor):*

Date:*

Date

Note: This notice is prepared in accordance with the Health Insurance Portability and Accountability Act, 45 C.F.R. If you have any questions, requests, or complaints in regards to our privacy policies and practices, please contact the HIPAA Compliance Officer at San Diego Family Dermatology: 655 Euclid Avenue, Suite 304, National City, CA 91950 (619) 267-8303 ● 222 W Madison Ave, El Cajon, CA 92020 (619) 579-5115 ● 15725 Pomerado Road, Suite 102, Poway, CA 92064 (619) 267-8303 ● 5222 Balboa Ave, Floor 5, San Diego, CA 92117 (619) 267-8303

The Open Payments database is a federal tool used to search payments made by drug and device companies to physicians and teaching hospitals. It can be found at https://openpaymentsdata.cms.gov

Cancellations: If you fail to provide 24 hour notice of a change in appointment and/or do not show for 3 or more appointments, you may be placed on a same-day only call list; we will only schedule you for same-day appointments based on availability. For surgery appointments, $50 will be charged for cancellations within 3 business days.

Type your initials here to acknowledge our Cancellation policy.*

Chaperones: For the comfort and safety of both patients and physicians, please be aware that our standard practice is for a medical assistant to be present with the doctor during all visits.

Financial Responsibility: We are committed to providing you with the best possible care, and will help you receive your maximum allowable insurance benefits. However, we need your assistance and your understanding of our payment policy. Your insurance contract is between you, your employer and the insurance company. Not all services are covered by all contracts. We participate and accept assignment from most major payers, which means covered charges, will be paid directly to us. As a courtesy to you, we will file a claim with your insurance carrier on your behalf. Any remaining balance will be billed to you once we have received payment from your insurance carrier. If we do not participate in your insurance plan or if you are uninsured, you may still choose to be seen in our practice as a “SELF PAY” patient. You may be eligible for a discounted “SELF PAY” rate that is due at time of service. If there is a lapse in your insurance, you are responsible for having knowledge of this. If you are unsure, check with your insurer before your appointment. If your insurance does not pay for your visit, you will be held responsible. It is your responsibility to know if we are contracted with your insurance company. At any time we hold the right to request payment ahead of services. If later paid by insurance you will be reimbursed. We do NOT accept insurances assigned to Scripps, Sharp, and UCSD. If your account becomes delinquent (past due), we may take the following actions: (1) refer your account to a collection agency, (2) file a lawsuit to recover the amount owed. If your account is referred to a collection agency, you agree to pay a collection fee and interest at an annual rate of 10% on the unpaid balance, beginning 30 days after the date of service. If legal action is required to collect the amount owed, you agree to pay all reasonable attorney's fees and court costs incurred in the collection process, in addition to the outstanding balance, collection fees, and interest.

Type your initials here to acknowledge our Financial Responsibility policy.*

Medication Refills:

For your safety, please note the below policy:

Refills on medications will be given for the time between office visits only. If you miss your follow-up, you will be allowed one refill in time to make another appointment.
Absolutely no refills will be provided to patients who have not been seen at SDFD in over 1 year.
New medications will not be prescribed for patients without having been seen in the past month.

Authorization: For patients who have an HMO for their insurance, we are required to ask for authorization to perform all procedures. Please note that your initial authorization may only include an office visit. As a courtesy to you, we will request authorization from your insurance for procedures. However, if you choose not to wait for authorization, you will be personally charged.

Tardiness: We value your time! And we hope you will value ours and other patients'. If you arrive more than 5 minutes late to an appointment, you may end up having to wait until there is a gap of time to be seen.

Same day appointments: If you have an urgent issue, for example a new rash that started in the last day or two, please call our office staff to arrange a same day appointment. After a brief assessment on the phone, you will be scheduled as soon as possible.

My signature below indicates my receipt and understanding of all office policies outlined in this document.

Patient Signature (or parent/guardian, if minor):*

Date*

Date

NOTICE OF PRIVACY PRACTICES & POLICIES

OPEN PAYMENTS DATABASE NOTICE

OFFICE POLICIES