TERRAP Online Form

It is important to contact your insurance and find out:

PLEASE READ THE FOLLOWING AGREEMENT CAREFULLY

1. All cancellations (no matter what the reason) must be made 24 hours in advance, otherwise YOU will be charged the full session fee.
2. Sessions are scheduled for 45 minutes. If you come late to session, we are unable to just our schedule.
3. It is understood and agreed that the client should give feedback, both positive and negative, to the therapist to maximize treatment benefits. It is further agreed that if I wish to terminate treatment at any time, or even reduce frequency of visits, I will discuss it with the therapist.
4. I agree to follow the verbal treatment plan formulated by the therapist. If I do not follow the treatment plan, the therapist has the right to terminate treatment.
5. Payment or co-payment is expected at the time of the office visit. Bounced checks will require a $25.00 bounced check fee.
6. All bills or insurance forms will be mailed out every two to four weeks depending your insurance.

Patient Previous Name(s)

I. My Authorization

You may use or disclose the following health care information (check all that apply):

You may disclose this health information to:

Information to be disclosed (check all that apply):

Reason(s) for this authorization (check all that apply):

This authorization ends:

THIS NOTICE DESCRIBES HOW PSYCHOLOGICAL AND MEDICAL INFORMTION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

I. Uses and Disclosures for Treatment, Payment, and Health Care Operations

I may use or disclose your protected health information (PHI), for treatment, payment, and health care operations purposes with your consent. To help clarify these terms, here are some definitions:

• "PHI" refers to information in your health record that could identify you.
• "Treatment, payment and Health Care Operations"
  • Treatment is when I provide, coordinate or manage your health care and other services related to your health care. An example of treatment would be when I consult with another health care provider, such as your family physician or another psychologist.
  • Payment is when I obtain reimbursement for your healthcare. Examples of payment are when I disclose you PHI to your health insurer to obtain reimbursement for your health care or to determine your eligibility or coverage.
  • Health Care Operations are activities that relate to the performance and operation of my practice. Examples of health care operations are quality assessment and improvement activities, business-related matters such as audits and administrative services, and case management and care coordination.
• "Use" applies only to activities within any of my offices, such as sharing, employing, applying, applying, utilizing, examining, and analyzing information that identifies you.
• "Disclosure" applies to activities outside of my offices, such as releasing, transferring, or providing access to information about you to other parties.

II. Uses and Disclosures Requiring Authorization

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 to obtain an authorization before releasing your psychotherapy notes. "Psychotherapy notes" are notes I have made about our conversation during a private, group, joint, or family counseling session, which I have kept separate from the rest of your medical record. These notes are given a greater degree of protection than PHI. I will also obtain an authorization from you before using or disclosing PHI in a way that is not described in this Notice.

You may revoke all such authorizations (of PHI or psychotherapy notes) at any time, provided each revocation is in writing. You may not revoke an authorization to the extent that (1) I have relied on that authorization; 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 policy.

III. Uses and Disclosures with Neither Consent nor Authorization

I may use or disclose PHI without your consent or authorization in the following circumstances:

• Child Abuse: If, in my professional capacity, a child come before me which I have reasonable cause to suspect is an abused or maltreated child, or I have reasonable cause to suspect a child is abused or maltreated where the parent, guardian, custodian or person legally responsible for such 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 an abused or maltreated child, I must report such abuse or maltreatment to the statewide central register of child abuse and maltreatment, or the local child protective services agency.
• Health Oversight: If there is an inquiry or complaint about my professional conduct to the New York State Board for Psychology, I must furnish to the New York Commissioner of Education, your confidential mental health records relevant to this inquiry.
• Judicial or Administrative Proceedings: If you are involved in a court proceeding and a request is made for information about the professional services that I have provided you and/or the records thereof, such information is privileged under state law, and I must not release this information without your written authorization, or a court order. This privilege does not apply when you are being evaluated for a third party or where the evaluation is court ordered. I must inform you in advance if this is the case.
• Serious Threat to Health or Safety: I may disclose your confidential information to protect you or others from a serious threat of harm by you.
• Worker's Compensation: If you file a worker's compensation claim, and I am treating you for the issues involved with that complaint, then I must furnish to the chairperson of the Worker's Compensation Board records which contain information regarding your psychological condition and treatment.
• When the use and disclosure without your consent or authorization is allowed under the sections of Section 164.512 of the Privacy Rule and the state's confidentiality law. This includes certain narrowlydefined disclosures to law enforcement agencies, to a health oversight agency (such as HHS or a state department of health), to a coroner or medical examiner, for public health purposes relating to disease or FDA-regulated products, or for specialized government functions such as fitness for military duties, eligibility for VA benefits, and security and intelligence.

IV. Patient's Rights and Psychologist's Duties

Patients Rights:

• Right to Request Restrictions-You have the right to request restrictions on certain uses and disclosures of protected health information about you. However, I am not required to agree to a restriction you request.
• Right to Receive Confidential Communications by Alternative Means at Alternative Locations- You have the right to request and receive confidential communications of PHI by alternative means and at alternative locations. (For example, you may not want a family member to know that you are seeing me. Upon your request, I will send your bills to another address.)
• Right to Inspect and Copy- You have the right to inspect or obtain a copy (or both) of PHI and Psychotherapy notes in my mental health billing records used to make decisions about you for as long as the PHI is maintained in the record. I may deny your access to the PHI under certain circumstances, but in some cases, you may have this decision reviewed. On your request, I will discuss with you the details of the request and denial process.
• Right to Amend- You have the right to request and amendment of PHI for as long as the PHI is maintained in the record. I may require you to make the request in writing to provide a reason to support a requested amendment. I may deny your request. On your request, I will discuss with you the details of the amendment process.
• Right to Accounting- You generally have the right to receive an accounting of disclosures of PHI for which you have neither provided consent nor authorization (as described in Section III of this Notice). On your request, I will discuss with you the details of the accounting process.
• Right to a paper Copy- You have the right to obtain a paper of the notice from me upon request, even if you have agreed to receive the notice electronically.
• Right to Restrict Disclosures When You Have Paid for Your Care Out-Of-Pocket- You have the right to restrict certain disclosures of PHI to a health plan when you pay out-of-pocket in full for my services.
• Right to be Notified if There is a breach of your Unsecured PHI- You have a right to be notified if: (a) there is a breach (a use or disclosure of your PHI in violation of the HIPAA Privacy Rule) involving your PHI; (b) that PHI has not been encrypted to government standards; and (c) my risk assessment fails to determine that there is a low probability that your PHI has been compromised.

Psychologist's Duties:

• I am required by law to maintain the privacy of PHI and to provide you with a notice of my legal duties and privacy practices with respect to PHI
• I reserve the right to change the privacy policies and practices described in this notice. Unless I notify you of such changes, however, I am required to abide by the terms currently in effect.
• If I revise my policies and procedures, I will notify you either in person or by mail.

V. Questions and Complaints

If you have any questions about this notice, disagree with a decision I make about access to your records, or have other concerns about your privacy rights, you may contact me at 631-549-8867.

You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services. I can provide you with the appropriate address upon request.

You have specific rights under the Privacy Rule. I will not regulate against you for exercising your right to file a complaint.

VI. Effective Date, Restrictions, and Changes to Privacy Policy

This notice will go into effect on October 1st, 2013.

I reserve the right to change the terms of this notice and to make the new notice provisions effective for all PHI that I maintain. I will provide you with a revised notice either in person or by mail.

During the course of treatment, it may be useful for us to communicate with you electronically, for example, via e-mail or text messages. The benefits of electronic communication can include:

• resolving scheduling and billing issues quickly and efficiently
• allowing your therapist to send reminders and appointment confirmations
• transmission of helpful resource material, worksheets, educational information, etc.
• access to your therapist remotely in between scheduled sessions, if you and your therapist have determined that this is clinically appropriate

We strive to provide you with convenient, timely means of communicating with us, and also make every effort to protect your privacy; however, electronic communication is never completely secure. Some potential risks of electronic communication include:

• others accessing your device in the case of loss/theft, or incidental contact at home/work
• e-mail accounts can be hacked
• text messages are stored on servers
• e-mails or text messages may be delivered to an incorrect address

My signature below indicates that I have been informed of and understand these risks and benefits of communicating electronically with TERRAP administrators and clinicians. I understand that I am not required to sign this agreement, and that I can terminate this consent at any time.

I understand that e-mail, text messaging, or any other forms of electronic communication should not be used in an emergency situation. In the case of an emergency, please call 911 or go to your nearest emergency room.

I DO NOT wish to allow electronic communication via (check off all that apply):