Policies and Forms
At the time of the appointment or before, please fill out the below forms patient and either mail them or email them via the provided HIPPA email. If you did not receive these forms via email, please contact our office at 646.369.2110 and ask that they be sent to you. The form will take approximately 20 minutes to complete before your first scheduled appointment.
The following policies are for review prior to the first appointment and do not need to be printed. I will review them with you at the first appointment.
Please disclose if you are involved in a legal matter (for example, custody, domestic violence, or visitation dispute) that may be litigated, and that the therapist’s testimony and records would likely be needed.
This therapist would decline the case since this therapist is uncomfortable with testifying in court and would be willing to refer the patient to another therapist.
EMAIL AND TEXT MESSAGES
Some of my patients prefer to communicate with their providers via email or text message. Email and text messages have inherent privacy and security risks, and you should be aware of those before using emails and text messages. Errors in the transmission or interception of messages can occur. Your email or text message is not a secure communication between you and your treating provider. At your healthcare provider’s discretion, your email or text message any and all responses may become part of your medical record. Additionally, for urgent or an emergency situation, you should not rely on email communication with this provider, or any person affiliated with this private practice. In those situations, you should call 911.
Good Faith Estimate Policy
You have the right to receive a “good faith estimate” explaining how much your mental health care will cost. You can also ask your health care provider, and any other provider you choose, for a good faith estimate before you schedule an appointment or service.
Under the law, healthcare providers must give patients who don’t have insurance or are not using insurance an estimate of the bill for services. The current estimated fee for a 45-minute psychotherapy session is $200.00, due at the time of the session. The frequency and duration of ongoing therapy sessions vary, depending on the patient’s comfort level, symptoms, emotional needs, and condition. Typically, sessions can range from several months to several years.
TO PROTECT THE PRIVACY OF YOUR HEALTH INFORMATION, THIS NOTICE DESCRIBES HOW PSYCHOTHERAPY AND MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
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/social worker. – Payment is when I obtain reimbursement for your healthcare. Examples of payment are when I disclose your PHI to your health insurer to obtain reimbursement for your health care or to determine 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 my [office, clinic, practice group, etc.] such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.
• “Disclosure” applies to activities outside of my [office, clinic, practice group, etc.], 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 healthcare 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 healthcare operations, I will obtain 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. 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 the policy.
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 I have reasonable cause to believe that a child has been subject to abuse, I must report this immediately to the New Jersey Division of Youth and Family Services.
▪ Adult and Domestic Abuse: If I reasonably believe that a vulnerable adult is subject of abuse, neglect, or exploitation, I may report the information to the county adult protective services provider.
▪ Health Oversight: If the New Jersey State Board of Social Work Examiners issues a subpoena, I may be compelled to testify before the Board and produce your relevant records and papers.
▪ 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 written authorization from you or your legally appointed representative, or a court order.
This privilege does not apply when you are being evaluated by a third party or where the evaluation is court-ordered. I will inform you in advance if this is the case.
▪ Serious Threat to Health or Safety: If you communicate to me a threat of imminent serious physical violence against a readily identifiable victim or yourself or the public and I believe you intend to carry out that treat, I must take steps to warn and protect. I also must take such steps if I believe you intend to carry out such violence, even if you have not made a specific verbal threat. The steps I take to warn and protect may include arranging for you to be admitted to a psychiatric unit of a hospital or other health care facility, advising the police of your threat and the identity of the intended victim, warning the intended victim or his or her parents if the intended victim is under 18, ad warning your parents if you are under 18.
▪ Worker’s Compensation: If you file a worker’s compensation claim, I may be required to release relevant information from your mental health records to a participant in the worker’s compensation case, a reinsurer, the health care provider, medical and non-medical experts in connection with the case, the Division of Worker’s Compensation, or the Compensation Rating and Inspection Bureau.
Patient’s Rights and Social Worker’s Duties:
Patient’s 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 the restriction you request.
▪ Right to Receive Confidential Communications by Alternative Means and 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 health and 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 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 an amendment of PHI for as long as the PHI is maintained in the record. I may deny your request. At your request, I will discuss with you the details of the amendment process.
▪ Right to an Accounting – You generally have the right to receive an accounting of disclosures of PHI for which you have neither provided consent nor authorization At 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 copy of the notice from me upon request, even if you have agreed to receive the notice electronically.
Social Workers 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 present you with a revised notice.
Questions and Complaints
If you have 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 talk with me about it. If you believe that your privacy rights have been violated and wish to file a complaint with me, you may send your written complaint to me. You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services. You have specific rights under the Privacy Rule. I will not retaliate against you for exercising your right to file a complaint.
Effective Date, Restrictions, and Changes to Privacy Policy
This notice will go into effect on February 2, 2022. 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 at that time.
Form 1
Authorization for Release or Exchange of Confidential Information
I hereby authorize the following provider to release or exchange confidential information pertaining to my Bio-psycho-social, social work, medical, psychological, and/or psychiatric history. This information is being requested for the purpose of completing patient assessment and treatment.
Provider Name: ______________________________________
Address:_________________________________________________________________________________
City: ____________________
State: ______________
Zip: ____________
Phone #: _____________________
I understand that I may revoke this consent at any time by informing the above parties in writing. However, my revocation will not be effective to the extent that action has been taken in reliance on the authorization. I understand that information used or disclosed pursuant to the authorization may be subject to re-disclosure by the recipient of your information and no longer protected by the HIPPA Privacy Rule.
Name of Patient Signature of Patient Date ______________________________/____________________
Signature of Parent/Guardian Date _____________________________/_____________________
Witness Signature Date
______________________________/__________________
Form 2
Tele-mental Health Informed Consent
I, _____________________________________, hereby consent to participate in tele-mental health with, ______________________________________________, as part of my psychotherapy. I understand that tele-mental health is the practice of delivering clinical health care services via technology-assisted media or other electronic means between a practitioner and a client who are located in two different locations.
I understand the following with respect to tele-mental health:
1) I understand that I have the right to withdraw consent at any time without affecting my right to future care, services, or program benefits to which I would otherwise be entitled.
2) I understand that there are risks, benefits, and consequences associated with tele-mental health, including but not limited to, disruption of transmission by technology failures, interruption and/or breaches of confidentiality by unauthorized persons, and/or limited ability to respond to emergencies.
3) I understand that there will be no recording of any of the online sessions by either party. All information disclosed within sessions and written records pertaining to those sessions are confidential and may not be disclosed to anyone without written authorization, except where the disclosure is permitted and/or required by law.
4) I understand that the privacy laws that protect the confidentiality of my protected health information (PHI) also apply to tele-mental health unless an exception to confidentiality applies (i.e., mandatory reporting of child, elder, or vulnerable adult abuse; danger to self or others; I raise mental/emotional health as an issue in a legal proceeding).
5) I understand that if I am having suicidal or homicidal thoughts, actively experiencing psychotic symptoms or experiencing a mental health crisis that cannot be resolved remotely, it may be determined that tele-mental health services are not appropriate, and a higher level of care is required.
6) I understand that during a tele-mental health session, we could encounter technical difficulties resulting in service interruptions. If this occurs, end and restart the session. If we are unable to reconnect within ten minutes, please call me at 646.369.2110 to discuss this since we may have to re-schedule.
7) I understand that my therapist may need to contact my emergency contact and/or appropriate authorities in case of an emergency.
Emergency Protocols
I need to know your location in case of an emergency. You agree to inform me of the address where you are at the beginning of each session. I also need a contact person who I may contact on your behalf in a life-threatening emergency only. This person will only be contacted to go to your location or take you to the hospital in the event of an emergency.
In case of an emergency, my location is: __________________________________________
and my emergency contact person’s name, address, phone: ______________________________________________
____________________________________________________________________________________________
I have read the information provided above and discussed it with my therapist. I understand the information contained in this form and all of my questions have been answered to my satisfaction.
__________________________________________________
Signature of client/parent/legal guardian Date
__________________________________________________
Signature of therapist Date
Please contact me with any questions that you may have. I look forward to hearing from you!