Carefully read our Notices and Policies below, then click button to continue to Registration Step 3.

Do not proceed if you have not read, or have not understood, the information on this page. You will be required to sign the Policy Acknowledgement under New Patient (3) on the next page.

This notice describes how health information about you may be used and disclosed, and how you can get access to this information. Please review this information carefully.

The doctors and staff at Cerbo Clinic PC (“we”) understand the importance of privacy and are committed to maintaining the confidentiality of your medical information. We make a record of the medical care we provide and may receive such records from others. We use these records to provide or enable other healthcare 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 medical practice 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 information, 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 at (650) 257-2976.


How we may use or disclose your health information

The medical record is the property of this medical practice, but the information in the medical record belongs to you. The law permits us to use or disclose your health information for the following purposes:


Treatment

We use medical information about you to provide your medical care. We disclose medical information to our employees and others who are involved in providing the care you need. For example, we may share your medical information with other physicians or other healthcare 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 medical information to members of your family or others who can help you when you are sick or injured, or following your death. In addition we work with organizations to provide telemedicine consultations with patients.


Payment

We use and disclose medical 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 healthcare providers to assist them in obtaining payment for services they have provided to you.


Notification and communication with family

We may disclose your health information to notify or assist in notifying a family member, your personal representative or another person responsible for your care. This includes information 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.


Health care operations

We may use and disclose medical information about you to operate this medical practice. For example, we may use and disclose this information to review and improve the quality of care we provide, or the competence and qualifications of our 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 medical reviews, legal services and audits, including fraud and abuse detection and compliance programs and business planning and management. We may also share your medical information with our business associates, such as the electronic medical records system provider and 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 medical 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 healthcare 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 healthcare costs, protocol development, case management or care coordination activities, their review of competence, qualifications and performance of healthcare 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.


Appointment Reminders

We may use and disclose medical 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.
Sign-in Sheet. We may use and disclose medical 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.


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.


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 personal 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.
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.


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.


Marketing

Provided that 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 will not use or disclose your medical information for marketing purposes or accept any payment for 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.


Coroners

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


Organ or tissue donation

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


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. 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.


Workers’ compensation

We may disclose your health information as necessary to comply with workers’ 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.


Change of ownership

In the event that this medical practice 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.


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 provide the notification. We may also provide notification by other methods as appropriate.


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.


When we may NOT use or disclose your health information

Except as described in this Notice of Privacy Practices, this medical practice 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.

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 request, 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.

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.


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.


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 available 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.


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 section A 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.


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 under

https://www.cerboclinic.com/privacy-practices/


Complaints

Complaints about this Notice of Privacy Practices or how this medical practice handles your health information should be directed in writing to:

Cerbo Clinic Privacy Officer

555 Bryant St, Ste 909

Palo Alto CA 94301


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

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

For more information on HIPAA and your privacy rights, you may visit the US Department of Health and Human Services website. You will not be penalized in any way for filing a complaint.

I authorize the direct payment of my insurance benefits to Cerbo Clinic PC for services rendered now or in the future. I understand that all co-pays, deductibles and co-insurance must be paid the day of each visit.

I authorize Cerbo Clinic PC to submit claims for services rendered without requiring my signature on each claim. I also authorize the release of relevant information, including diagnoses, treatment records and photos for claim processing.

I understand this service is provided for me as a courtesy only and does not substitute for payment. Many insurance companies pay fixed allowances for certain procedures, while many others pay a percentage of the charge. “Reasonable and Customary Fees” are determined by the insurance carrier and may vary greatly between carriers.

It is my responsibility to pay any deductible amount, co-insurance, co-pay, out-of-pocket or any other balance not covered by my insurance company. Co-pays for surgery are due two weeks prior to the surgery date.

If my insurance does not honor this assignment, makes payments directly to me, or fails to pay within 90 days, I understand I am responsible for paying any outstanding balances.

My signature on the Patient Forms consent page confirms that I understand and agree to the above policy.

CONSENT TO USE EMAIL, WEBFORMS, SMS/TEXT MESSAGING AND THIRD PARTY COMMUNICATION APPS

1. RISKS OF USING WEB-BASED COMMUNICATION (E-MAIL, WEB FORMS, TEXT AND SMS MESSAGING, AND THIRD PARTY COMMUNICATION APPS)


Cerbo Clinic, through their electronic medical record (EMR) vendor, Practice Fusion, offers patients and their legal guardians the opportunity to communicate directly using e-mail or text messaging. Secure patient access is provided through Practice Fusion’s patient portal “PatientFusion”.

Cerbo Clinic also uses secure web based communications including webforms and Third Party encrypted messaging apps (e.g. WhatsApp).

Each of these communication tools can facilitate better communication and there is great utility in improving communication between doctors and patients, to facilitate delivery of patient care.

However, using these web based electronic communication tools is different than traditional phone messaging. We encourage you to read up on the issues around electronic web based communication and the risks and caveats described below. Please take the time to understand your options and risks before using web based tools for communication with Cerbo Clinic.

Cerbo Clinic offers web based tools to facilitate appointment scheduling and payments. These tools are not intended to be used to convey medical information or to discuss medical conditions. You should only discuss details of your medical care with your physician, either on the phone or in person.

E-mail, text messaging, web page forms and third party communication apps have a number of possible risks that patients and their legal guardians should be aware of, prior to communicating with Cerbo Clinic through any of these tools.

If the patient or legal guardian is worried about any information being seen by other people, or if the question or problem is urgent, then other form(s) of communication such as telephone communication should be used.

Some of the possible risks of using web-based communications, such as e-mail, web forms, text messaging or third party apps include, but are not limited to, the following:

a. E-mail information or text messages can be sent on to other people, stored on a computer, or printed out on paper for storage.

b. E-mail or text messages can be sent out and received by many recipients, some or all of whom may be sent the e-mail accidently.

c. E-mail or text message senders can easily misaddress their message.

d. E-mail or text message information is easier to change than handwritten or signed documents.

e. E-mail or text message information may be kept on computers/electronic devices even after the sender or the recipient believes they deleted his or her copy.

f. Employers and on-line services have a right to archive (store) and look at e-mails and text messages transmitted through their systems. Some, but not all, employers store e-mail and text messages indefinitely.

g. E-mails, text messages, web form entries and Third Party app entries can occasionally be intercepted, changed, forwarded, or used without authorization or detection.

h. E-mails, text messages, and web forms can be used to introduce viruses into computer systems.

i. E-mail or text messages can be used as evidence in court.

j. Information sent through web forms or third party messaging apps may be intercepted and stored by third party vendors who may or may not subscribe to the legal mandates for Private Health Information (PHI) protections, such as those granted through State and Federal law (e.g. Health Insurance Portability and Accountability Act of 1996 (HIPAA).



2. CONDITIONS FOR THE USE OF E-MAIL, WEB FORMS, TEXT MESSAGING AND THIRD PARTY COMMUNICATION APPS

The health care providers will use reasonable means to protect the security and confidentiality of any and all information sent and received.

However, because of the risks outlined above, the health care providers cannot guarantee the security and confidentiality (privacy) of e-mails, text messaging communications, and of information exchanged through web forms and use of third party web based tools such as WhatsApp.

Cerbo Clinic will not be liable for improper use and/ or disclosure of confidential information (including Protected Health Information (PHI) that is the subject of the Federal Health Insurance Portability and Accountability Act of 1996 (HIPAA)).


Thus, if the patient/ legal guardian chooses to exchange Protected Health Information (PHI) with Cerbo Clinic through web based means (such as text messaging/ SMS, E-mail, Web Forms, Third Party Apps e.g. WhatsApp), patient or legal guardian must consent to the use of web-based tools for patient information.


Consent to the use of e-mail, text messaging, web form submissions, and use of Third Party communication tools includes agreement with the following conditions:

a. E-mails, text messages or other electronic communication to or from the patient/ legal guardian concerning diagnosis or treatment will be printed out and/or made part of the patient’s medical record. Because they are then a part of the medical record, other individuals who are authorized to view the medical record, such as staff and billing workforce members, will also have access to those e-mails.

b. The health care providers may forward e-mails, text messages or other web based communications internally to other staff or agents of the health care providers/ their practice as necessary for diagnosis, treatment, reimbursement, and other operations. The health care providers will not, however, forward e-mail or text messages or web form entries to independent Third Parties outside of Cerbo Clinic who are not involved with the patient’s treatment, reimbursement, or otherwise involved in their care, without the patient’s or legal guardian’s prior written consent, except as authorized or required by law. The health care providers may possibly forward e-mails, text messages, and other web based communications to other health care providers participating in the patient’s care.

c. Although the health care providers will try to read and respond quickly to an e-mail or text message or web form entry or WhatsApp message from the patient or legal guardian, the health care providers cannot guarantee that any particular message or e-mail will be read and responded to within any particular period of time. The usual period of time is one (1) business day, but it may take up to a week or longer if the person to whom the e-mail or message is sent to is away, or if the e-mail system or online communication system is not working. Thus, the patient or legal guardian should not use e-mail, text messaging, or web-based communications for medical emergencies or other matters that have to be handled quickly.

d. Text messages are used by health care providers for appointment reminders or to share more generic information. When text messages are sent by a patient or legal guardian there should not be an expectation of a response from the health care provider.

e. If the patient or legal guardian’s e-mail requires or invites a response from the health care provider, and the patient/parent/legal guardian has not received a response within a reasonable time period, it is the patient’s or legal guardian’s responsibility to call the practice in order to determine whether the intended recipient received the e-mail, and when the recipient will respond. As an alternative, the patient or legal guardian can discuss the issue by telephone.

f. The patient or legal guardian should not use e-mail or text messages or web forms or WhatsApp to discuss any subjects that the patient or legal guardian feels should be kept confidential, such as sensitive medical information regarding sexually transmitted diseases, AIDS/HIV, mental health, developmental disability, or substance abuse.

g. Where applicable, there may be a provider charge for the time necessary to respond to the e-mails and web based messages.

h. The patient or legal guardian is responsible for protecting his/ her password or other means of access to e-mail or text messaging or WhatApp. The health care provider or his/ her practice is not liable for information that is read by other people through errors caused by the patient or legal guardian or any Third Party.

i. The health care provider or his/ her practice cannot engage in e-mail or text message or other web based communication that is unlawful, such as practicing medicine across state lines. If through e-mail or text message or other online communication, the health care provider determines that an office or hospital visit is necessary to address the problem, or if the patient or legal guardian wants to have such a visit, it is the patient’s or legal guardian’s responsibility to schedule the appointment at the physical locations of Cerbo Clinic (Peninsula Office in Redwood City, CA or South Bay Office in San Jose, CA).



3. INSTRUCTIONS

To communicate by e-mail or text message or web form use or Third Party communication apps, the patient or legal guardian is advised to:

a. Limit or avoid use of his/ her employer’s computer. Information is often stored on the employer’s system and can be read by people within that organization.

b. Inform the health care provider/ practice of changes in e-mail, mobile phone numbers, or text messaging addresses.

c. Help the health care provider and practice to ensure that they are communicating about the right person, by putting the patient’s full name and date of birth in the body of the first e-mail message to the provider and/or practice and not in the subject line.

d. In order for the e-mail to be forwarded to the proper person, include the category of the communication in the e-mail’s subject line, (e.g., “I have a question to my neurosurgeon about my upcoming surgery” or “I need to reschedule my appointment” or “I have a question about my recent bill”). This helps us to respond to your queries more quickly.

e. Review the e-mail or text message to make sure it is clear and that all needed information is provided before sending to the health care provider or practice. E-mails from health care providers will be encrypted or sent through the PatientFusion portal for secure access.

f. The first time you receive an email you will get a notice email from PatientFusion and you will have to set up your user name and password with them. This user name and password will be required to access the first and all future emails.

g. Take precautions to preserve the confidentiality of e-mails or text messages, such as using screen savers and safeguarding computer passwords.

h. Withdraw consent only by e-mail or written communication to the health care provider and/or practice.

i. Contact the health care provider and/or practice at their provided telephone number with any questions about using e- mail or text messaging. This should be done before sending an e-mail to the health care provider and/or practice.

4. PATIENT ACKNOWLEDGMENT AND AGREEMENT – INFORMED CONSENT

I acknowledge that I have read and fully understand the information Cerbo Clinic has provided me regarding the risks of using web based tools including e-mail, text messaging, web forms, and Third Party communication apps.

I understand the risks associated with the communication of web based tools including e-mail, text messaging, web forms, and Third Party communication apps between the health care provider and the practice and me, and consent to the conditions outlined in this document.

In addition, I agree to the above instructions, as well as any other instructions that Cerbo Clinic and Cerbo Clinic doctors may impose regarding web based communications including e-mail, text messages, web based forms and Third Party communication apps. 

My signature on the Patient Forms consent page confirms that I have read and agree with the above Communication Policy.

Cerbo Clinic asks you for permission to obtain your Medication Prescription History.  

Medication Prescription History is a list of prescription drugs and medicines that our surgeon, your family doctor, or other providers have prescribed for you.

Medication Prescription History helps healthcare providers treat your symptoms and/ or illnesses properly. Knowing the medicines you take helps in avoiding potentially dangerous drug interactions. This information is especially important during hospitalization for surgery.

It is very important that you and your doctor discuss all your medications in order to ensure that your recorded Medication Prescription History is 100% accurate.

A variety of sources, including pharmacies and health insurers, contribute to the collection of your medication history.

Your Medication Prescription History is securely stored in the practice electronic medical record system (EHR/ EMR) and becomes part of your personal medical record.  

Please note that some pharmacies do not make Medication Prescription History information available, and your Medication Prescription History may not include drugs purchased without using your health insurance.

Please note also that over-the-counter drugs, supplements and/ or herbal remedies that you take on your own may not be included. Please make sure to disclose any and all medications and supplements to our surgeon during your visit. Bring your pill and supplement bottles with you to your first appointment so that we can make sure we record your medications correctly.

By signing the consent form on the Patient Forms page you are giving Cerbo Clinic permission to collect your Medication Prescription History. You are giving your pharmacy and your health insurer permission to disclose information about your prescriptions to us. This includes any prescriptions that have been filled at any pharmacy or covered by any health insurance plan.

To provide the best possible care for you, Cerbo Clinic uses ambient scribe technology, a computer tool that listens to the conversation and creates a summary in your medical record. 

Like using a human scribe, your surgeon can focus on you and less on typing on a computer. The ambient scribe does not interact with you directly. Once the note has been created, your surgeon reviews it for accuracy and makes the necessary edits.

The scribe tool does not keep records. The final notes are kept in your secure health record. Cerbo Clinic follows strict privacy practices including Health Insurance Portability and Accountability Act (HIPAA). Only the healthcare professionals involved in your care will have access to these notes.

Your participation is completely voluntary. If you agree to the use of ambient scribe during your consultations, please sign and date the consent form provided in Patient Forms. Ask us if you have any questions about ambient scribe technology.