NO SURPRISES ACT STANDARD NOTICE
Right to Receive a Good Faith Estimate of Expected Charges Under the No Surprises Act
You have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost.Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services.· You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees.· Make sure your health care provider gives you a Good Faith Estimate in writing at least one business day before your medical service or item. You can also ask your health care provider and any other provider you choose for a Good Faith Estimate before you schedule an item or service.· If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill.· Make sure to save a copy or picture of your Good Faith Estimate.For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises, call 917-854-7092, or email hello@unionsquarect.com. HIPAA NEW YORK NOTICE FORM
Notice of Psychologist’s Policies and Practices to Protect the Privacy of Your Health Information
THIS NOTICE DESCRIBES HOW PSYCHOLOGICAL AND MEDICAL INFORMATION 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” is when I provide, coordinate, or manage your health care and other services
related to your 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 health care. 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-based practice, such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.
“Disclosure” apples to activities outside of my office-based practice, 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 authorization from your before releasing this information. I will also need to obtain an authorization before releasing your psychotherapy notes. “Psychotherapy notes” are notes that 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.
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 comes 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 other 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 of Psychology, I must furnish to the New York Commissioner for 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 for you and/or 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 issues involved with that complaint, then I must furnish to the chairman of the Worker’s Compensation Board records which contain information regarding your psychological condition and treatment.
IV. Patient’s Rights and Psychologist’s Duties Patient’s Rights:
Right to Request Restrictions – You have the right to request restrictions on certain uses and disclosures of PHI about you. However, I am not required to agree to a 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 alterative locations. (For example, you may not want a family member to know that you are seeing me. Upon your request, I will send 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 and billing records used to make decisions about you for as long as the PHI is maintained in my 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 the 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. On 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 (as described in Section II 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 copy of the notice from me upon request, even if you have agreed to receive the notice electronically.
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 mail the revised notice to you, as well as making it available in my office.
V. 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 contact Dr. Rene Zweig at (917) 386-4950 or zweig@unionsquarect.com.
If you believe that your privacy rights have been violated, please contact Dr. Rene Zweig at (917) 386- 4950 or zweig@unionsquarect.com about your concerns. If you do not feel comfortable doing this, you may call The New York State Psychology Licensing Board at 1-800-442-8106. You may also address your complaints to the Secretary of the U.S. Department of Health and Human Services by obtaining their contact information on their website at www.hhs.gov/ocr/hipaa.
VI. Effective Date, Restrictions, and Changes to Privacy Policy
This notice will go into effect on February 2, 2010.
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 the revised notice by distributing it in the office and/or mailing it to your home address.
VII. Consent for Treatment
I have read and understood this policy statement. I accept, understand, and agree to abide by the contents and terms of this agreement and further, consent to participate in evaluation and/or treatment. I understand that I may withdraw from treatment at any time.