Child, Adolescent and Adult Psychiatrist and Psychotherapist

Quddusa Doongerwala, M.D. Child, Adolescent and Adult Psychiatrist and Psychotherapist 101 S. San Mateo Drive, Suite 204, San Mateo, CA 94401 Phone: (650) 380-6955 Fax: (650) 622-9535

Privacy, Confidentiality and Patients Rights Policies

Your application for services at the office of Dr. Doongerwala includes questionnaires that you are requested to complete and return. In receiving subsequent services at Dr. Doongerwala’s office additional information will be requested. This information is necessary for her to have in order to offer and provide appropriate and indicated diagnostic and treatment services. The policy and practice attempts to safeguard your right to privacy and confidentiality of this information are the following:

1. All information, both written and oral, which you provide to Dr. Doongerwala, will be maintained in confidential files. 2. This information, as well as all of Dr. Doongerwala’s diagnostic and treatment reports or other information concerning you, will NOT be made available to other individuals or organizations without your written consent, except in the case of legal order or subpoena. 3. All information concerning you will be utilized within the office of Dr. Doongerwala by professional staff in order to determine indicated and appropriate diagnostic and treatment services to be offered and provided. 4. If Dr. Doongerwala determines it appropriate you may access to her reports and information concerning you and may review it with Dr. Doongerwala at a mutually convenient time. You may have copies of particular reports at your expense. 5. Your medical records are released only with your specific written consent except for some situations in which the doctor is expected or required by California law to disclose patient information to outside agencies or third parties. These situations include reports of abuse to children or elders, report of neglect, intent to harm someone, domestic violence and under certain circumstances when ordered by a court. Although confidential, if a child or adult reports intent to harm themselves or someone else, or reports grave disability the doctor will act to ensure safety. 6. Dr. Doongerwala accepts a patient into treatment in an effort to determine whether he or she can benefit from the services available. If, in the opinion of Dr. Doongerwala he or she is not able to benefit, withdrawal will be recommended and other plans discussed

I have read and understand the policy described above and accept the terms

______Date Signature