To avoid being charged $80.00, a 24 hour notice is required for all cancelled/missed appointments. You are
responsible for notifying the office of all name, address, phone number and insurance changes as soon as possible
to avoid a claim being denied. Please understand that you are ultimately responsible for all fees incurred in the
event that the insurance carrier does not pay. Returned checks will result in a $30.00 charged fee. All fees not
paid within 90 days will be sent to a collection agency, and a 35% processing fee will be added to your account.
Statements will be sent out periodically. For patients ages 17 and younger, the parent or guardian who signed
these forms is responsible for any outstanding balance.
This notice explains how your protected health information may be disclosed as necessary for treatment, payment and health care operations, and the exceptions and rights therein.
Uses and Disclosures for Treatment, Payment and Health Care Operation Activities
A client has the right to impose restrictions on the use or disclosure of PHI in some circumstances in which use or disclosure would otherwise be permitted under HIPPA.
This health care provider may use or disclose your protected health information (PHI), for treatment, payment and health care purposes with your consent. PHI is information in your health record that could identify you. Treatment is when we provide, coordinate or manage your health care and/or other services related to your health care. An example of treatment would be consulting with another healthcare provider, your family, physician or psychiatrist as needed.
Payment is when we obtain reimbursement for your health care and other services related to your health care. This would be information necessary to obtain insurance reimbursement and determine your insurance eligibility.
Health Care Operations are activities that relate to the performance and operations of our counseling services, such as…quality assessment, improvement activities, business-related matters such as audits and administrative services, and case management and coordination.
Use applies only to activities within this office, clinic, practice, or group; the sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.
Disclosure applies to activities outside of the office, clinic, practice group etc. such as releasing, transferring, or providing access to information about you to other parties.
I may use or disclose PHI for purposes outside of treatment, payment and health care operations when your appropriate authorization is obtained. An Authorization is written permission above and beyond the general consent that permits only specific disclosures. In those instances when I am asked for information for purposes outside of treatment, payment and health care operations, I will obtain an authorization from you before releasing this information. I will also need an authorization signed by you or your legally responsible party before I can release the progress notes we keep about you in your file. You may revoke each release in writing except (1) to the extent I have relied on it or (2) if the authorization was obtained as a condition of obtaining insurance coverage, and the law provides the insurer the right to contest the claim under the policy. You have the right to request a restriction of the Privacy Officer, and a determination will be made as to whether it was permissible and notify you regarding the results of the review of your request.
Child Abuse- If in my professional opinion, I have reasonable suspicion or a child comes before me indicating that they are abused or maltreated, or where a parent, guardian, custodian or other personal legally responsible for the child comes before me in my professional or official capacity and states from personal knowledge facts, conditions or circumstances which, if correct, would render the child abused or maltreated, I am mandated to report such abuse or maltreatment to the statewide central register of child and maltreatment, or the local child protective services.
Health Oversight- If there is a question regarding a professional conduct complaint that the NYS Commissioner is investigating regarding your case, the records relevant to this inquiry will be disclosed.
Judicial or Administrative Proceedings- If a judge orders your record due to you being involved in a court proceeding you will be notified of the request, however we cannot deny access to your record. If it is ordered by an attorney an authorization is necessary from you.
Serious Threat to Health or Safety of Yourself or Another- I may disclose your confidential information to protect you or others from a serious threat or harm by you.
Medical Emergency- In case of a medical emergency, your emergency contact and the medical professionals involved will be notified with the minimal amount of your health information necessary for you to receive the proper emergency medical attention.
Right to request restrictions- You have the right to request restrictions on certain uses and disclosures of your PHI. You may request that the Covered Entity restrict use or disclosure or PHI for purposes of treatment, payment and health care operations, and may request a restriction on information given to family members, friends and others involved in your care. This restriction request will be reviewed by the Privacy Officer (owner of operation), and you will be notified of the result. Requests for restrictions on the use of PHI for treatment, payment, and health care operations must be made in writing on a request for Restriction on Use and Disclosure of Health Information Form. The Privacy Officer will review the request and may accept or reject the request as permitted by law. You will be notified of the disposition on your request in writing, and a copy of this letter will be kept in your file.
Right to receive your confidential communication by alternate means or locations- Upon request, any correspondence from this office can be sent to an alternate location to protect your privacy.
Right to inspect and copy- You have the right to inspect or obtain both a copy of your PHI and psychotherapy notes in your mental health and billing records, however you may be denied access in certain circumstances. If access is denied, you may have this decision reviewed.
Right to an accounting record- You have the right to the accounting of PHI sent without your consent nor authorization as described in sections a. – e. listed above.
as part of my psychotherapy. I understand that
“telemedicine” includes the practice of healthcare delivery, diagnosis, consultation, treatment, transfer of medical data, and education using interactive audio, video, or data communications.
I understand that I have the following rights with respect to telemedicine:
I have the right to withhold or withdraw consent at any time without affecting my right to future care or treatment nor risking the loss or withdrawal or any program benefits to which I would otherwise be entitled.
The laws that protect the confidentiality of my medical information also apply to telemedicine. As such, I understand that the information disclosed by me during the course of my therapy is generally confidential. However, there are both mandatory and permissive exceptions to confidentiality, including, but not limited to reporting child, elder, and dependent adult abuse; expressed threats of violence towards an ascertainable victim; and where I make my mental or emotional state an issue in a legal proceeding. I also understand that the dissemination of any personally identifiable images or information from the telemedicine interaction to researchers or other entities shall not occur without my written consent.
I understand that there are risks and consequences from telemedicine, including, but not limited to, the possibility, despite reasonable efforts on the part of my psychotherapist, that: the transmission of my medical information could be disrupted or distorted by technical failures; the transmission of my medical information could be interrupted by unauthorized persons; and/or the electronic storage of my medical information could be accessed by unauthorized persons. In addition, I understand that telemedicine-based services and care may not be as complete as face-to-face services. I also understand that if my psychotherapist believes I would be better served by another form of psychotherapeutic services (e.g. face-to-face services) I will be referred to a psychotherapist who can provide such services in my area. Finally, I understand that there are potential risks and benefits associated with any form of psychotherapy, and that despite my efforts and the efforts of my psychotherapist, my condition may not improve, and in some cases may even get worse.
I understand that I may benefit from telemedicine, but that results cannot be guaranteed or assured.
I understand that I have a right to access my medical information and copies of medical records in accordance with New York State law, upon written request. To obtain these records, please submit your written request at least 72 hours prior to when you need them available.
I have read and understand the information stated above. You will have the opportunity to discuss this information and ask any questions you may have with your psychotherapist.
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