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

I am required by law to maintain the privacy of your protected health information and to provide you with this Notice of Privacy Practices ("Notice") of my legal duties and privacy practices with respect to your protected health information.

The Health Insurance Portability and Accountability Act (HIPAA) is a federal law that provides privacy protection with regard to the use and disclosure of your clinical records (also known as your Protected Health Information or PHI) for the purposes of treatment, payment, and health care operations. This describes the ways in which I may use and disclose your PHI.  It also describes your rights and my legal obligations with respect to your PHI.   

I reserve the right to change the privacy policies and practices described in this Notice. Unless I notify you by mail of changes, I am required to abide by the terms in this Notice.

EXPLANATION OF USES AND DISCLOSURES:

1.         For treatment:  I may use and disclose your PHI to provide you with treatment and related services.  For example, in order to provide the best possible clinical care for my clients, I may seek professional consultation, such as with your physician.  Any other professional with whom I discuss clinical information with is also legally bound to keep the information confidential.

2.         For Payment: I may use and disclose your PHI to bill and receive payment for the treatment and services I provide.  For example, I may inform your insurance company upon your request to obtain the appropriate approvals and/or to confirm coverage for your treatment.

3.         For Health Care Operations: I may also use and disclose your PHI as necessary to operate my practice.  For example, I may use and disclose your PHI:

-               To review and improve the quality of care you receive;

-               To my lawyers, consultants, accountants, and other business associates, including, without limitation, my telecommunications provider (currently, CounSol) to allow me to communicate through written messaging, video and instant message sessions;

-               To organizations that evaluate, certify or license me;

-               If I sell my practice or merge with another health care entity; and

-               To send you appointment reminders.

4.  Treatment of Couples: In the treatment of couples, both clients must consent to the release of treatment records. When consent is not given, records will only be released with a court order.

 5.   Treatment of Minors: Clients under 18 years of age who are not emancipated should be aware that the law may allow both parents the right to examine their treatment records. Privacy in psychotherapy is very important to the success of treatment and I will likely ask parents to respect the need for confidentiality in their child's therapy relationship. Under most circumstances, some parental involvement in a child's treatment is essential to successful therapy outcomes. When children are age 12 or older, I will request that an agreement be made between my client and parent(s) to share general information about treatment progress and compliance with scheduled appointments. Other communication about what is shared in session between the child and me will require the child's authorization.  An exception to this agreement would be if I feel that the child may be in danger or is a danger to someone else, in which case, parents will be notified of the concern.  I will do my best to discuss these kinds of concerns with the child beforehand if this type of disclosure to a parent becomes necessary.  

6.   Uses and Disclosures Requiring Authorization:   With some limited exceptions, I need to obtain your authorization before releasing your Psychotherapy Notes-notes I have made about your conversations during a counseling session, which may be kept separate from the rest of your record. These notes are given a greater degree of protection than other PHI. You may revoke all such authorizations at any time, provided each revocation is in writing. You may not revoke an authorization to the extent that (1) I have already released information based 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.

 I MAY ALSO USE AND DISCLOSE YOUR PHI WITHOUT YOUR AUTHORIZATION IN LIMITED SITUATIONS.

The following are situations in which I may use or disclose your PHI without your written authorization or an opportunity for you to agree or object, as described below.

-           As Required by Law:  I may disclose your PHI when required to do so by federal, state or local law or other judicial or administrative proceedings.

-           Emergencies:  If a client threatens to harm herself/himself, I may be obligated to seek hospitalization for her/him, or to contact family members or others who can provide protection. In addition, if a client communicates an immediate threat of serious physical harm to an identifiable victim, I may be required to take protective actions. These actions may include notifying the potential victim, contacting the police, or seeking hospitalization for the patient.

 -           Individuals Involved in Your Care or Payment for Your Care:  Unless you object, I may disclose PHI about you to a family member, relative, close personal friend or any other person you identify, including clergy, who is involved in your care.  These disclosures are limited to information relevant to the person's involvement in your care or in payment for your care.

-           Reporting Victims of Abuse or Neglect:  In the event that a client discloses information that provides evidence of current abuse including neglect of a minor child, or a disabled or elderly adult, the law requires that I report this to the appropriate state agency.

-           Health Oversight Activities:  When authorized by law, I may disclose your PHI to a health oversight agency for activities, such as audits, investigations, inspections, licensure actions or other legal proceedings.  A health oversight agency is a state or federal agency that oversees the health care system.

-           Judicial and Administrative Proceedings:  If a client files a complaint or lawsuit against me, I may disclose relevant information regarding that client in order to defend myself.  In addition, I may disclose your PHI in response to a court or an administrative order.  In certain circumstances, I also may disclose PHI in response to a subpoena, a discovery request, or any other lawful process by another party involved in the action.  I will make a reasonable effort to inform you about the request.

-           Law Enforcement:  I may disclose your PHI for certain law enforcement purposes, such as: reports required by law; identifying or locating a suspect or missing person, material witness or fugitive; and answering certain requests for information concerning crimes, about the victim of crimes.

-           Military and Veterans:  If you are a member of the armed forces, I may use and disclose your PHI as required by military command authorities.  I may also disclose your PHI to the appropriate foreign military authority if you are a member of a foreign military.

-           National Security and Intelligence Activities: I may disclose PHI to authorized federal officials conducting national security, counterintelligence, and intelligence activities authorized by law.  I may also disclose your PHI to authorized federal officials, as needed, to provide protection to the President of the United States, other authorized persons, foreign heads of states or to conduct certain special investigations.

-           Workers' Compensation:  If I am providing treatment for conditions directly related to worker's compensation claim, I may have to submit such records, upon appropriate request, to the Chairman of the Worker's Compensation Board on such forms and at such times as the Chairman may require.

YOUR RIGHTS

You have the following rights regarding your PHI that I maintain:

1.         The Right to Access Your PHI:  Except under limited circumstances, and upon written request, you have the right to inspect and obtain a copy of your PHI.  Under current New York law, I may charge you no more than 75 cents per page, plus first-class postage, if I make a copy of your medical record.  To inspect and request a copy of your PHI, you should submit your written request to me.  I must respond to your request within 30 days, by either supplying the records or sending a written notification of denial.  If you are denied access to your PHI, in some cases you will have the right to request a review of this denial.  The review will be performed by a licensed health care professional designated by me, who did not participate in the original decision to deny access.

2.         The Right to Request Restrictions:  You have the right to request a restriction on the way I use or disclose your PHI for treatment, payment or health care operations.  You also have the right to request restrictions on the PHI that I disclose about you to a family member, friend or other person involved in your care or the payment of your care.  If you wish to request such a restriction, you should submit your written request to me.  You must tell me what information you want restricted, to whom you want the information restricted, and whether you want to limit my use, disclosure or both.

Generally, I am not required to agree to such a restriction.  If I do agree to the restriction, I will honor that restriction except as needed to provide you with emergency treatment.

I am required to honor your requested restriction that I withhold PHI from your insurance plan, subject to you paying for the services you do not wish disclosed, and other specific details.  If you wish to request such a restriction, please let me know immediately.  I will provide you with additional details on how to obtain this restriction.  Be advised, Medicaid may not allow you to make this request.  

3.         The Right to Request Confidential Communications:  You have the right to request that I communicate with you concerning your health matters in a certain manner or at a certain location.  For example, you can request that I contact you only at a certain phone number or a specific address. You should submit your written request for confidential communications to me.  You must tell me how and where you want to be contacted.  I will accommodate your reasonable requests, but may deny the request if you are unable to provide me with appropriate methods of contacting you.

4.         The Right to Request an Amendment:  You have the right to request that I amend medical or billing records, or other PHI maintained by me, for as long as the information is kept by me.  Your request must be made in writing and must explain the reasons for the requested amendment. I may deny your request for amendment if the information: was not created by me (unless you prove the creator of the information is no longer available to amend the record); is not part of the records maintained by me; in my opinion, is information that is accurate and complete; and is information to which you do not have a right of access.

I must respond to your request within 60 days of receiving the request.  If I agree to the amendment, I will notify you and amend the relevant portions of your medical record.  I will also make a reasonable effort to inform business associates and other individuals known to me, or identified by you, as having the PHI being amended.

If I deny your request for amendment, I will give you a written denial notice, including the reasons for the denial and explain to you that you have the right to submit a written statement disagreeing with the denial.  Your statement of disagreement will be attached to your medical record.  If you should submit a statement of disagreement, I have the right to insert a rebuttal statement into the medical record.  I will provide you with a copy of the rebuttal statement.  If you do not wish to submit a statement of disagreement, you may request that a copy of the amendment request and a copy of my denial be included with all future disclosures.

Should I deny your request for an amendment, you have the right to pursue a complaint process by contacting the Secretary of Health and Human Services to lodge your complaint.

If you wish to request an amendment, you should submit the request to me in writing.

5.         The Right to An Accounting of Disclosures:  You have the right to request an accounting of certain disclosures of your PHI.  You may request an accounting of disclosures made up to six (6) years before the date of your request.  An accounting is a listing of disclosures made by me or by others on my behalf, but does not include: disclosures made for treatment, payment and health care operations; disclosures made directly to you, that you authorized, or those which are made to individuals involved in your care; disclosure made to correctional institutions or law enforcement official about an inmate in custody; disclosure made for national security or intelligence purposes; disclosure of a limited data set; or an incidental disclosure.

You must submit your request for an accounting of disclosures to me in writing.  You must state the time period for which you would like the accounting.  I must respond to you 60 days after receipt of your request.  The accounting will include the disclosure date, the name, address (if known) of the person or entity that received the information, a brief description of the information disclosed, and a brief statement of the purpose of the disclosure.  If you request a listing of disclosures more than once within a 12-month period, I will charge you a reasonable fee for the accounting.  The first accounting, within a 12-month period, is provided to you at no charge.

6.         The Right to a Paper Copy of This Notice: You have the right to obtain a paper copy of this Notice, even if you have agreed to receive this Notice electronically.  You may request a copy of this Notice at any time by contacting my office in writing or by phone.

7.         Right to Be Notified of a Breach of Unsecured PHI.  You have the right to be notified in the event there is a breach of your unsecured PHI.  While I never expect this to happen, if it does, I will contact you (usually by mailing a letter, but I might also call you) to explain what happened, and provide you with additional details and I will let you know that who you can call at my office for more information.

8.         Right to request restrictions as a self-pay patient.  You have the right to restrict certain disclosures of health information to a health plan if you pay for a service in full and out of pocket. If you choose to restrict any information under this circumstance, you must submit your request in writing to laurafedericotherapy@gmail.com.

COMPLAINTS

If you believe I have violated your privacy rights, or you disagree with a decision I made about access to your records, you have the right to file a complaint in writing with me and/or with the Secretary of Health and Human Services at 200 Independence Avenue, S.W. Washington, D.C. 20201 or by calling (202) 619-0257. You may also contact the New York Professional Misconduct Enforcement System at 1-800-442-8106 or conduct@mail.nysed.gov. I will not retaliate against you for filing a complaint

As a Licensed Clinical Social Worker, I am governed by various laws and regulations and by the code of ethics of my profession. The ethics code requires that I make you aware of my specific office policies and procedures, how these policies and procedures may affect you, as well as your patient rights. I welcome any questions you may have about this document and will address them during your intake appointment. This document contains this important information and serves as your informed consent for treatment. By completing and submitting the form located at the top of this page, you are electronically signing and acknowledging your understanding, agreement, and consent to the terms and conditions of this Treatment Agreement.

Scheduling:

Once a given hour is held for you, it is difficult to fill on short notice if you cancel. Other than for true emergencies, it is expected that you will attend your scheduled hour. If canceling is necessary, I require a minimum of 24 hours notice; if notice is given under 24 hours, I will charge you for the session fee. I try to accommodate requests to reschedule when conflicts arise, though it must be within the same week of your appointment time and is subject to my availability.

Communication:

I am available by telephone or email between scheduled sessions. Since I am not always immediately available, I check my email and voicemail messages and make every effort to return your call or email within 24 hours, except for weekends and holidays. If you are unable to reach me and feel that you cannot wait for my return call, and/or are in crisis or danger to harm yourself or others, you should contact your nearest emergency room or call 911. If I will be unavailable for an extended period of time (vacation, etc), I will provide you with the name of a colleague to contact in my absence.

I regularly use email for practical scheduling or other business-related matters (ie billing). Yet it is strongly recommended to avoid sending anything of a personal nature via email due to its lack of security as a communication medium.

Fees:

My full fee for an individual, 50 minute psychotherapy session or consultation is $250, unless you participate in the NYU Wellfleet insurance plan, which will require a co-pay. For patients without the NYU insurance, my hourly fee will be reviewed annually and/or whenever your financial situation substantially changes. If a true hardship exists, I will take such matters into consideration. If finances prohibit us from continuing to work together, I will do my best to direct you towards a lower- fee referral.

Fees can either be paid at the time of service or billed monthly, and paid no later than 14 days after receipt of the invoice. Please discuss with me if circumstances prohibit you from paying your bill on a weekly or monthly basis. I am unable to accumulate balances; if your account is more than 60 days past-due and suitable arrangements for payment have not been agreed upon, I have the option of suspending or discontinuing your treatment.

Insurance:

Please note that I only participate in the Wellfleet NYU insurance plan. I am willing to provide patients  without this plan receipts or other paperwork necessary to receive reimbursement as an out-of-network provider. However, you (not your insurance company), are responsible for full payment of the mutually agreed upon fee. Therefore, it is important that you determine exactly what mental health services your insurance policy covers and the conditions of the coverage.

Ending Treatment:

You have the right to end treatment at any time. Should you decide between sessions to withdraw from therapy, I request that you attend at least one additional session to discuss the reasons with me.

PROFESSIONAL RECORDS

The laws and standards of my profession require that I keep Protected Health Information (PHI) about you in your clinical record. Your clinical record may contain information such as a diagnosis, intake information, consent to treatment, treatment plan, phone and electronic contact, and treatment notes. Treatment notes are brief summaries of our individual sessions outlining important issues, facts, or any treatment recommendations discussed. Except in unusual circumstances that involve danger to yourself and/or others or where information has been supplied to me confidentially by others, you may request in writing to examine and/or receive a copy of your clinical record. These are professional records that can be misinterpreted and/or upsetting to untrained readers. For this reason, I strongly recommend that you review them in my presence or upon your written consent, have them sent to another mental health professional to review with you.

CONFIDENTIALITY & NOTICE OF PRIVACY PRACTICES

The Health Insurance Portability and Accountability Act (HIPAA) is a federal law that provides privacy protection with regard to the use and disclosure of your clinical records (also known as your Protected Health Information or PHI) used for the purpose of treatment, payments, and health care operations. I will make every effort to safeguard the privacy of information concerning our work together. It is unethical for me to disclose any information regarding your treatment with me, with a few exceptions.

You may authorize me to release records or other information to individuals of your choosing (insurance companies, family members, other providers, etc). This may only be done with your expressed written consent.In order to provide the best possible clinical care for my clients, I seek professional supervision and consultation. During professional supervision or consultation, I will make every effort to avoid revealing the identity of my client. Any other professional with whom I discuss clinical information with is also legally bound to keep the information confidential.Disclosures required by health insurers or to collect overdue fees are discussed elsewhere in this Contract.If I am providing treatment for conditions directly related to worker's compensation claim, I may have to submit such records, upon appropriate request, to Chairman of the Worker's Compensation Board on such forms and at such times as the chairman may require.If a client files a complaint or lawsuit against me, I may disclose relevant information regarding that client in order to defend myself.If a government agency is requesting the information for health oversight activities, I may be required to provide it for them.In certain legal proceedings, confidential information may be disclosed by court order. This is a rare occurrence and would not happen without your knowledge.Treatment of Couples: In the treatment of couples, both clients must consent the release of treatment records. When consent is not given, records will only be release with a court order.Treatment of Minors: Clients under 18 years of age who are not emancipated should be aware that the law may allow both parents the right to examine their treatment records. Privacy in psychotherapy is very important to the success of treatment and I will likely ask parents to respect the need for confidentiality in their child's therapy relationship. Under most circumstances, some parental involvement in a child's treatment is essential to successful therapy outcomes. When children are age 12 or older, I will request that an agreement be made between my client and parent(s) to share general information about treatment progress and compliance with scheduled appointments. Other communication about the what is shared in session between the child and me will require the child's authorization.  An exception to this agreement would be if I feel that the child may be in danger or is a danger to someone else, in which case, parents will be notified of the concern.  I will do my best to discuss these kinds of concerns with the child beforehand if this type of disclosure to a parent becomes necessary.   

There are some situations in which I am legally obligated to take actions in an attempt to protect others from harm. In this rare and unusual event, I may be required to reveal some information about a client's treatment.

If a client communicates an immediate threat of serious physical harm to an identifiable victim, I may be required to take protective actions. These actions may include notifying the potential victim, contacting the police, or seeking hospitalization for the patient.If a client threatens to harm herself/himself, I may be obligated to seek hospitalization for her/him, or to contact family members or others who can provide protection.In the event that a client discloses information that provides evidence of current abuse including neglect of a minor child, or a disabled or elderly adult, the law requires that I report this to the appropriate state agency.

PATIENT RIGHTS

HIPAA provides you with several new or expanded rights with regard to your clinical records and disclosure of Protected Health Information (PHI). These rights include: requesting to amend your clinical record; requesting to place restrictions on what information from your clinical records is disclosed to others; requesting an accounting of most disclosures of Protected Health Information that you have neither consented to nor authorized; determining the location to which Protected Health Information disclosures are sent; having any complaints you make about my policies and procedures recorded in your records; requesting a paper copy of this Psychotherapy Services Contract including this Notice of Privacy Practices; and refusing or ending treatment at any time for any reason. 

If you believe I have violated your privacy rights, or you disagree with a decision I made about access to your records, you have the right to file a complaint in writing with me and/or with the Secretary of Health and Human Services at 200 Independence Avenue, S.W. Washington, D.C. 20201 or by calling (202) 619-0257. You may also contact the New York Professional Misconduct Enforcement System at 1-800-442-8106 or conduct@mail.nysed.gov. I will not retaliate against you for filing a complaint.