Primary Care Physician Information
Please take a few minutes to read the following information carefully to avoid any future misunderstanding.
Your session time is reserved for you. I do not schedule other patients during any part of your time. The time duration for individual therapy is 45 minutes and for couple therapy is 60 minutes. If you are utilizing EAP benefits for couple therapy, the session will be 45 minutes. In order to achieve the full benefit from therapy, it is important that you arrive on time to your sessions and maintain a consistent attendance. I will not be able to provide you with additional time if you arrive late to your session. If you cancel your appointment, you will be responsible for your therapy payment unless your cancelation is 48-hours prior to your appointment. If you cancel frequently, you may be asked to terminate your treatmnet since continuity is essential for a successful outcome.
Kindly make all out-of-pocket payments in full at the time of service (co-payment, deductable, etc.). If, for any reason, your insurance company does not pay for sevices or does not authorize visits, you will be responsible for the counseling fee. All effort will be made to obtain payment, financial statement will be mailed to your home. Please submit payment promptly. If you are unable to pay your balance in full, please contact the office to make a payment arrangement. In the event that we do not receive any payment, please be aware that the basic demographic information will be provided to an outside agency for collection of any unpaid fees.
I hereby authorize Shirley Court Gonzales, LCSW, BCD at 470 Prospect Avenue, Suite 302, West Orange, NJ 07052 to provide services as agreed upon. I authotize this provider to furnish information to the insurance carrier concerning this treatment, and I hereby, irrevocably, assign to the provider all payments for services while in treatment.
I understand and agree to the office policy.
HIPAA NOTICE OF PRIVACY PRACTICES
I. THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOUR TREATMENT MAYBE USED AND DISCLOSED, AND HOW YOU CAN OBTAIN ACCESS TO THE INFORMATION.
This notice is provided to you pursuant to the Health Insurance Portability and Accessibility Act of 1996 and its implementing regulations (HIPPA). It is designed to tell you how your information, under Federal Law, may beused or disclosed.
II. IT IS MY LEGAL DUTY TO SAFEGUARD YOUR PROTECTED HEALTH INFORMATION (PHI).
By law I am required to insure that your PHI is kept private. The PHI constitutes information created or noted by me that can be used to identify you. It contains dates and information about your health and condition, provisions of health care service to you and/or payment for such health care. I am required to provide you with the Notice about my privacy procedures. This notice must explain when, why andhow I would use and/or disclose your PHI. Use of PHImeans when I share, apply, utilize, examine or analyze information within my practice; PHI is disclosed when I release, transfer, give or otherwise reveal any part of your PHIto athird party outside of my practice. With some exceptions, I may not use or disclosed more of your PHI than is necessary to accomplish the purpose of which the use or disclosure is made; however, I am always legally required to follow the privacy practices described in this Notice.
Please note that I reserve the right to change the terms of this Notice andmyprivacy policies atany time. Any changes will apply to the PHI already onfile. Before I make any important changes to mypolicies, I will immediately change his Notice.
III. HOW I WILL USE AND DISCLOSE YOUR PROTECTED HEALTH INFORMATION
A. Uses and Disclosures That Do Not Require Your Authorimtion.
According to the Privacy rules, I may use and disclose your PHI without your authorization for the following purposes:
B. Certain other Uses and Disclosures That Do Not Require Your Consent.
I may use and/or disclose your PHI without your consent or authorization for the following reasons: Notification. Unless you object, I may use or disclose protected health information to family members,personal representative, or other persons responsible for your care, but you must request disclosure in writing I will respond within 30 days after I receive your request.Under certain circumstances, I may deny your request. If I do, I will give you, in writing, my reason for denial and explain your right to have my denial reviewed. (If you ask for copies of your PHI, I will charge you not more than $.25 per page.Upon agreement, you may receive asummary or explanation of the PHI.
C. The Right to Get a List of Any Disclosures.
You are entitled to a list of disclosures that I havemade of your PHI. This list will not include uses and disclosures madefor the purpose of treatment, payment or health care operations, those made pursuant to your written authorization, or those made directly to you or your family. This list also will not include uses and disclosures madefor the national security purposes,to corrections or law enforcement personnel,or disclosures made before or prior to April 14,2011. After April 15,2011, disclosure records will be heldfor six (6) years. I will respond to your request for an accounting of disclosures within sixty (60) days of receiving your request. The list will include disclosures made in the previous six years unless you indicate a shorter period.
D. The Right to Correct or Update Your PHI.
If you believe that there is a mistake in your PHI or that important information has been omitted, it is your right to request that I correct the existing information or add the missing information. You must provide the request and the reason for the request, in writing. You will receive aresponse with sixty (60) days of the receipt of your request also in writing. I may deny your request, in writing, if I find that the PHI is correct and complete, it is not created by me, it does not allow to be disclosed, or it is not part of my record. My denial must be in writing and must state the reason for the denial. It must also explain your right to file a written statement objecting to the denial. If I approve of your request, I will make the change to the PHI,and advise you and others involved in your care, of the changes.
IV. IF YOU FEEL THAT YOUR PRIVACY RIGHTS HAVE BEEN VIOLATED.
If, in your opinion. I have violated your privacy rights, or if you object to adecision I made about access to your PHI. You are entitled to file a complaint with the person listed in Section V below. You may also send a written complaint to the Secretary of the Department of Health and Human Services, at 200 Independence Avenue SW, Washington. DC.20201.
V. PERSON TO CONTACT FOR INFORMATION ABOUT THIS NOTICE OR TO MAKE A PRIVACY VIOLATION COMPLAINT.
If you have any questions about this Notice or any complaint about my privacy practices, or would like to know how to file acomplaint with the Secretary of the Department of Health and Human Services, please contact Shirley Court Gonzalez, LCSW, BCD at 470 Prospect Avenue, Suite 302, West Orange, NJ (877) 755-4401.
VI. EFFECTIVE DATE OF THIS NOTICE.
This Notice went into effect on April 14,2011.
I acknowledge receipt of this Notice.
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