患者入院表格

确认收到隐私惯例通知

我们需要向您提供我们的隐私惯例通知的副本，其中说明了我们如何使用和/或披露您的健康信息。请签署此表格以确认收到通知。如果您愿意，您可以拒绝签署此确认书。

我承认我已收到办公室的隐私惯例通知的副本。

消费者须知

自 2010 年 6 月 27 日起，一项由商业和职业法规第 138 条第 16 条、加利福尼亚法规第 1355.4 条规定的新法规要求加利福尼亚州的医生告知其患者以下内容：

“医生获得加利福尼亚医学委员会的许可和监管”(800) 633-2322，www.mbc.ca.gov。

患者办公室政策

The following information is provided to help you understand office policy and procedures. We request your credit card information on file. If you have any questions please do not hesitate to ask Dr. Ma or the office staff.

破损的预约费用

When appointments are scheduled, 30 minutes is reserved for each follow up appointment. A $300 charge is incurred for appointments cancelled after hours the day prior, or the same day.

电话咨询费

The charge for a telephone consultation reflects total time spent at $500 per hour. This includes the telephone call, writing the medical note, and filling a prescription to the pharmacy, if this is done.

Medication Refill Charges

Usually, medications run out because patients have not scheduled their follow-up appointment. Filling medication requires that Dr. Ma review the chart, interpret the situation, record a medical note justifying why the medication had to be filled without an appointment, with instructions regarding the medication, dosage, quantity, and pharmacy number. The medication is then sent into the pharmacy. Medication refill charges reflect total time spent at rate of $250 per hour. We also offer a flat fee of $50 per prescription. Medication refills may take up to 3 business days to be processed. Please plan accordingly and contact us ahead of time to ensure sufficient supply.

Medication refills may take up to 3 business days to be processed. Please plan accordingly and contact us ahead of time to ensure sufficient supply.

电话/电子邮件通信政策

Phone and email communication is not intended for emergencies and may be unencrypted or otherwise not secure. Please NEVER send any confidential and/or health information, including medication refill requests. If you choose such communication, you will bear sole responsibility and release the practice including my doctor and Office staff from any liability for any adverse consequences. I acknowledge that I have read and agree to the policy on phone/email correspondence.

Emergency

If you are experiencing a psychiatric emergency, please either call the San Diego Crisis Line at 1- 888-724-7240 or go directly to the nearest hospital emergency room

High risk behavior

I agree I will not attempt to end my life while I’m under the care of My Doctor and My Doctor’s associates. If I have strong urges to end my life, I will call 911 or go to the nearest Emergency Room so I can be evaluated and treated before I do anything to harm myself. My family and I will not hold My Doctor and My Doctor’s associates and My Doctor’s office liable if I attempt to or succeed in ending my life.

Duty to Warn

My Doctor and Office staffs have the duty to inform the Department of Child or Adult Protective Services if I reveal to them that I or someone I know is actively abusing a minor or an elder. They also have the duty to inform the Police Department if I reveal to them that I am going to physically hurt or plan to kill someone.

Pregnancy

Psychiatric medications can be harmful to a fetus. If I want to become pregnant or if I discover that I am pregnant during my treatment, I will discuss my situation with my doctor and my doctor’s associates immediately. I will not hold them liable if there are any adverse effects to my fetus due to my taking of psychiatric medications.

Treatment Outcome

The treatment of mental disorders, relationship problems, and other mental conditions require different treatments such as medications, psychotherapy, after- session assignments, support groups, and habit changes. There is ample evidence that these treatments work for some people at most of the time. However, there is no guarantee that any of these treatments will work for my specific condition. I’m willing to accept that fact going into treatment.

Long-term disability

I understand My doctor’s office does not help the application of long-term disability.

Short-term disability

I understand My doctor and My doctor’s associates have to evaluate me every week to assess if I am still qualify for it based on my condition. The maximum total duration won’t exceed 6 months. My Doctor won’t initiate the short-term disability under any circumstance if I am a new patient to the office.

We do not fill out disability forms for clients new to our practice. For clients who are well-established and attend their appointments regularly, your psychiatrist may fill out disability forms at their discretion and on a case-by-case basis. Your psychiatrist will ask that you schedule an additional appointment in order to discuss the form.

Emotional support animal (ESA)

I understand My doctor’s office does not help to write any ESA letters or a letter to bring emotional animals aboard the flight.

Form/Letter fee

I agree to pay a fee for any forms/Letter I ask my doctor’s office to complete. My doctor’s office reserves the right to decide which form/Letter is appropriate based on the clinical evidence. The fee is ranged from $300.00 to $500.00 per case.

Urine Drug Screen (UDS)

My doctor and My Doctor’s associates can order UDS anytime during my treatment

Public Encounter

At times, I may encounter My Doctor in a public setting. My Doctor wants to protect my privacy and will not acknowledge me as a patient unless I am comfortable revealing that information and acknowledge that I’m My Doctor’s patient first. This also applies to My Doctor’s associates and staff.

Legal Testimony

Legal matters may require the testimony of a mental health professional. Dr. Ma will decline to participate in any legal proceedings, even if it is on your behalf, as participation in any role outside of clinical care is a conflict of interest and will likely negatively interfere with the doctor/patient relationship.

Initial Evaluation

The initial psychiatric evaluation is a consultation focused on assessment, which is not guaranteed to establish doctor-patient relationship. This can be scheduled upto 30-60 minutes. If the evaluation cannot be completed within the allotted time, you have the option of extending the initial appointment time for an additional charge if Dr. Ma’s schedule allows.

Termination

The doctor-patient relationship can be maintained between my doctor, my doctor’s associates and me for as long as I continue to be compliant with recommended treatment. If I cancel my appointment and/or do not show up for my appointment, or violate any Office Policy, or I do not contact my doctor’s office within the timeframe of their making three attempts to contact me or three months since the last appointment. My doctor’s office can terminate this relationship and cease to provide any service including any refill request.

This agreement is between My Doctor and me

隐私惯例通知

本通知描述了您的医疗信息如何被使用和披露，以及您如何访问这些信息。请仔细查看。

本通知是什么以及为什么重要？

As of April of 2003, a new federal law (“HIPAA”) went into effect. This law requires that health care practitioners create a notice of privacy practices for you to read. This notice tells you how I, CI MA, M.D., will protect your medical information, how I may use or disclose this information, and describes your rights. If you have any questions about this notice, please contact me at (858) 848-5386.

了解您的健康信息

在每次约会期间，我都会记录临床信息并将其存储在您的图表中。通常，此记录包括对您的症状、您最近的压力源、您的医疗问题、精神状态检查、任何相关的实验室测试结果、诊断、治疗和未来护理计划的描述。此信息通常称为您的医疗记录，可用作：

• 计划您的护理和治疗的依据 • 为您提供护理的卫生专业人员之间的沟通方式
• 您接受的护理的法律文件
• 您或第三方付款人（例如健康保险公司）可以用来验证您收到的服务是否正确计费的方法
• 一种工具，我可以使用它来评估和改善我提供的护理

您的健康信息权利 您拥有以下与您的病历相关的权利：

• 获取本通知的副本。您可以在候诊室阅读此通知，如果您愿意，也可以获取自己的副本。
• 授权使用您的健康信息。在我使用或披露您的健康信息之前，除下文所述之外，我将获得您的书面授权，您可以随时撤销该授权以停止未来的使用或披露。
• 访问您的健康信息。您可以随时向我索取一份您的病历副本。
• 更改您的健康信息。如果您认为您记录中的信息不准确或不完整，您可以要求我更正或添加信息。
• 请求保密通信。您可以要求当我与您就您的健康信息进行沟通时，我会以特定方式（例如，通过特定的邮件地址或电话号码）这样做。我将尽一切合理努力同意您的要求。
• 披露的会计。您可以要求一份我出于治疗、付款或医疗保健业务以外的原因而披露的您的健康信息的清单。

我的职责

• 法律要求我保护您的健康信息的隐私，提供有关我的隐私惯例的通知，并遵守本通知的条款。
• 我保留更改我保护健康信息的政策和程序的权利。当我对使用或披露您的健康信息的方式做出重大改变时，我也会更改此通知。
• 除与您的治疗、为我的服务收取费用、履行必要的业务职能或法律允许或要求的其他目的外，未经您的授权，我不会使用或披露您的健康信息。您有权随时撤销您的授权。

我什么时候可以在未经您特别同意的情况下合法披露您的健康信息？

为了方便您就医。

例如：您的初级保健医师或心理治疗师可能会打电话给我讨论您的治疗，在这种情况下，我会披露有关您的诊断、药物等信息。

为了收取我提供的医疗保健服务的费用。

例如：为了获得我的服务报酬，我让我的账单办公室向您或您的保险公司寄送账单。账单上的信息可能包括识别您身份的信息，以及您的诊断和治疗类型。在其他情况下，我会填写授权表格，以便您的保险公司支付额外的访问费用，其中包括有关您的一些信息，包括您的诊断。

为了方便日常办公操作。

例如：有时，我会口述就诊记录，通常是写给其他临床医生的信。在这种情况下，您的健康信息将被披露给转录员。

我会向家人和朋友透露您的健康信息吗？

虽然新法律允许在未经您特别同意的情况下进行此类披露（只要它有助于您的治疗），但我的办公室政策是，未经您的授权，我绝不会与您的家人分享您的临床信息。最大的例外是，如果我认为您对自己或他人构成直接危险——在这种情况下，我会做任何必要的事情，即使这意味着违反保密规定。

我可能会披露您的健康信息的不太常见的情况

• 工伤赔偿：我可能会披露您的健康信息以遵守与工伤赔偿或其他类似计划相关的法律。
• 执法：我可能会根据法律要求或响应有效的传票、法院或行政命令，出于执法目的披露您的健康信息。这包括社会服务部 (DSS) 要求的与忽视或虐待儿童案件有关的任何信息。
• 食品和药物管理局 (FDA)：我可能会向 FDA 披露您与药物引起的不良事件有关的健康信息。
• 商业伙伴：我聘请了一家计费公司将账单寄给保险公司。这家公司的一些员工可以访问您的一小部分健康信息，以便他们能够完成工作。

欲了解更多信息或报告问题

如果您有任何疑问、想了解更多信息或想要获取本通知的更新副本，您可以致电 858-848-5386 与我 (CI MA, MD) 联系。如果您认为您的隐私权受到任何形式的侵犯，请告诉我，我将采取适当的措施。

You may also send a written complaint to:
 Department of Health & Human Services, Office of Civil Rights, Hubert H. Humphrey Building 200 Independence Avenue
S.W. Room 509 HHH Building 
Washington, D.C. 20201

HIPAA 隐私惯例的摘要通知

本通知描述了您的医疗信息如何被使用和披露，您可以访问这些信息。请仔细检查。

这是随后较长通知的一页摘要。请阅读摘要和实际通知。

HIPAA 允许我在未经您特别同意的情况下分享您的健康信息，以便：

• 方便您的治疗
• 获得保险公司的付款
• 转录记录

我可能会向以下实体披露您的健康信息：

• Other health care providers and therapists
• Insurance companies

• Practice billing service

• Practice transcriptionist
• Workers Compensation Boards.
• The FDA
• Law enforcement and DSS

注意：未经您的特别同意，我不会与您的家人分享您的信息，除非有人的健康处于直接危险之中。

远程治疗授权

Telepsychiatry provides psychiatric services using interactive video conferencing tools in which the psychiatrist and the patient are not at the same location. Telepsychiatry will allow the patient to receive medical care without the need to visit the office and travel long distance. Potential risks include, but may not be limited to: information transmitted may not be sufficient (poor resolution of video); delays in medical evaluation and treatment due to deficiencies or failures of the equipment; security protocols can fail, causing a breach of privacy; and a lack of access to all the information available in a face to face visit may result in errors in medical judgment. Alternative to telepsychiatry include traditional face to face sessions.

Your Rights:

1. I understand that the laws that protect the privacy and confidentiality of medical information also apply to telepsychiatry;
2. I understand that the interactive video conferencing tool, Doximity vs PsychologyTodayLink is known to incorporate network and software security protocols to protect the confidentiality of information and audio/visual data. These protocols include measures to safeguard the data and to aid in protecting against intentional or unintentional corruption.
3. I have the right to withdraw my consent to the use of telepsychiatry during the course of my care at any time.
4. I understand that Dr. Ma has the right to withhold or withdraw consent for the use of telepsychiatry during the course of my care at any time;
5. I understand that all rules and regulations which apply to the practice of medicine in the State of California also apply to telepsychiatry.

Your Responsibilities:

1. I will not record any telepsychiatry sessions without the prior written consent of Dr. Ma and I understand that Dr. Ma will not record telepsychiatry sessions without my consent.
2. I will inform Dr. Ma if any other person can hear or see any part of our session before the session begins. Likewise, Dr. Ma will inform me if any other person can hear or see any part of the session before the session begins.
3. I understand that I MUST be a resident of California to be eligible for telepsychiatry services from Dr. Ma.
4. I understand that my Initial Consultation will not be done by telepsychiatry except in special circumstances under which I will be required to verify my identity to Dr. Ma’s satisfaction before the evaluation.

Your signature below indicates that you have read and understand the information provided above regarding telepsychiatry, and that you authorize Dr. Ma to use telepsychiatry in the course of diagnosis and treatment.