BENJAMIN S. FIALKOFF, Ph.D.
Clinical Psychologist & Clinical Hypnotherapist
51 Chestnut Street, Suite 3, Ridgewood, New Jersey 07450-3837
201-652-3909
N.J. License No.:
35SI00123800 N.Y. License No.:
04976-1
Kay Faye
Fialkoff, Office Manager, Phone/Fax: 201-791-4320
N.J. License No.:
SIO1238
N. Y. License No.: 04976-1
Kay Faye Fialkoff, Office Manager, Phone/Fax:
201-791-4320
NEW JERSEY NOTICE FORM
Notice of
Psychologists’ 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, 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 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.
BENJAMIN
S. FIALKOFF, Ph.D.
Clinical
Psychologist & Clinical Hypnotherapist
NEW
JERSEY NOTICE FORM
(continued)
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 A“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 notesNotes”
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
clinical
record. These notes are given a
greater degree of protection than PHI.
You may revoke all such authorizations (of PHI or psychotherapy Psychotherapy notesNotes)
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:
For the State of
New Jersey:
·
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 the 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 Psychological
Examiners issues a subpoena, I may be compelled to testify before the Board and
produce your relevant records and papers.
BENJAMIN
S. FIALKOFF, Ph.D.
Clinical
Psychologist & Clinical Hypnotherapist
NEW
JERSEY NOTICE FORM
(continued)
·
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 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: If you communicate to me a threat of
imminent serious physical violence against a readily identifiable victim or
yourself and I believe you intend to carry out that threat, 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, and
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.
For the State of New
York:
·
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
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 chairman of the Worker’s Compensation Board records that 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 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 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.)
BENJAMIN
S. FIALKOFF, Ph.D.
Clinical
Psychologist & Clinical Hypnotherapist
NEW
JERSEY NOTICE FORM
(continued)
·
Right
to Inspect and Copy – You have the right to inspect or obtain
a copy (or both) of PHI and psychotherapy Psychotherapy notes Notes in my
mental 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. 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 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
copy of the notice from me upon request, even if you have agreed to receive the
notice electronically.
Psychologists’ 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 by mail.
·
. . .[Notice must also describe how the
psychologist will provide individuals with a revised notice, e.g., by mail.]
V. Complaints
If
you are concerned that I have violated your privacy rights, or you disagree
with a decision I made about access to your records, you may contact Kay Faye Fialkoff,
Office Manager, 201-791-4320.
BENJAMIN S. FIALKOFF,
Ph.D.
Clinical Psychologist
& Clinical Hypnotherapist
NEW JERSEY NOTICE
FORM
(continued)
You
may also send a written complaint to the Secretary of the U.S. Department of
Health and Human Services.
The U.S. Department
of Health and Human Services
200 Independence Avenue, S.W.
Washington,
D.C. 20201
Telephone:
202-619-0257
Toll Free:
1-877-696-6775
VI. Effective
Date, Restrictions and Changes to Privacy Policy
This notice will go into effect on _April 14, 2003.______________[add date, which
may not be earlier than the date on which the notice is printed or otherwise
published.]
[If
you (the psychologist) elect to limit the uses or disclosures that you are
permitted to make under this subpart, add the following:]
I will not limit
the uses or disclosures that I will make
as follows:______________________ at this time.
[Note
- You (the psychologist) may include in your notice a limitation (a
restriction) affecting your right to make a use or disclosure. This restriction, however, may not include a
limitation affecting the psychologist's right to make a use or disclosure that
is required by law or, when in good faith, to use or disclose to avert a
serious threat to health or safety of a person or the public and such use or
disclosure is made to a person or persons reasonably able to prevent or lessen
the threat (including the target of the threat)].
[If you (the
psychologist) want to apply a change in your more limited uses and disclosures
to PHI created or received prior to issuing a revised notice, the revised
notice must include a statement that you reserve the right to change the terms
of the notice and to make the new notice provisions effective for all protected
health information that you maintain.
The statement must also describe how you will provide individuals with a
revised notice. (See example below.)]
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 by _mail.___________________
[Describe how you
will provide individuals with a revised notice.]
Patient
Name:______________________Date:____________Signature:____________________
