Notice of Privacy Practices

HIPAA requires that I provide you with a Notice of Privacy Practices (the Notice) for use and disclosure of PHI for treatment, payment and healthcare operations. The law requires that I obtain your signature acknowledging that I have provided you with this. If you have any questions, it is your right and obligation to ask so I can have a further discussion prior to signing the intake form. When you sign, it will also represent an agreement between us. You may revoke this Agreement in writing at any time.

Reasons I may have to release your information without authorization:

If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the psychologist-patient privilege law. I cannot provide any information without your (or your legal representative's) written authorization, or a court order, or if I receive a subpoena of which you have been properly notified and you have failed to inform me that you oppose the subpoena. If you are involved in or contemplating litigation, you should consult with an attorney to determine whether a court would be likely to order me to disclose information.

If a government agency is requesting the information for health oversight activities, within its appropriate legal authority, I may be required to provide it for them.

If a patient files a complaint or lawsuit against me, I may disclose relevant information regarding that patient in order to defend myself.

I may disclose the minimum necessary health information to my business associates that perform functions on our behalf or provide us with services if the information is necessary for such functions or services. My business associates sign agreements to protect the privacy of your information and are not allowed to use or disclose any information other than as specified in our contract.

If I know, or have reason to suspect, that a child under 18 has been abused, abandoned, or neglected by a parent, legal custodian, caregiver, or any other person responsible for the child's welfare, the law requires that I file a report with the New Jersey Abuse Hotline. Once such a report is filed, I may be required to provide additional information.

Other Disclosures:

Treatment: We may use and disclose your child’s health information as part of assessment and intervention procedures. In addition, we may use and disclose your child’s information with other caregivers, professionals, or persons working with your child, only when given written consent.
Your Authorization: You may give us written authorization (Release of Information) to use your child’s information or disclose it to anyone for any purpose. If authorization is provided to me for any individual or entity you may revoke the authorization in writing at any time.
Appointment Reminders: We may use your child’s information for appointment reminders (i.e. voicemail, texts, emails, reminder cards)
Billing: We may use and disclose your child's health information to obtain payment for services we provide to you.

Patient's Rights:

Right to Treatment – You have the right to ethical treatment without discrimination in any regard.
Right to Confidentiality – You have the right to have your health care information protected. If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. I will agree to such unless a law requires us to share that information.
Right to Request Restrictions – You have the right to request restrictions on certain uses and disclosures of your PHI
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.
Right to Inspect and Copy – You have the right to inspect or obtain a copy (or both) of PHI. Records must be requested in writing and release of information must be completed. Please make your request well in advance and allow 2 weeks to receive the copies.
Right to Amend – If you believe the information in your records is incorrect and/or missing important information, you can ask us to make certain changes, also known as amending, to your health information. You have to make this request in writing.
Right to a Copy of This Notice – If you received the paperwork electronically, you have a copy in your email. If you completed this paperwork in the office at your first session a copy will be provided to you per your request or at any time.
Right to an Accounting – You generally have the right to receive an accounting of disclosures of PHI regarding you. On your request, I will discuss with you the details of the accounting process.
Right to Terminate – You have the right to terminate therapeutic services with me at any time without any legal or financial obligations other than those already accrued.

Notice of Privacy Practices

Reasons I may have to release your information without authorization:

If a government agency is requesting the information for health oversight activities, within its appropriate legal authority, I may be required to provide it for them.

If a patient files a complaint or lawsuit against me, I may disclose relevant information regarding that patient in order to defend myself.

Other Disclosures:

Treatment: We may use and disclose your child’s health information as part of assessment and intervention procedures. In addition, we may use and disclose your child’s information with other caregivers, professionals, or persons working with your child, only when given written consent.

Your Authorization: You may give us written authorization (Release of Information) to use your child’s information or disclose it to anyone for any purpose. If authorization is provided to me for any individual or entity you may revoke the authorization in writing at any time.

Appointment Reminders: We may use your child’s information for appointment reminders (i.e. voicemail, texts, emails, reminder cards)

Billing: We may use and disclose your child's health information to obtain payment for services we provide to you.

Patient's Rights:

Right to Treatment – You have the right to ethical treatment without discrimination in any regard.

Right to Request Restrictions – You have the right to request restrictions on certain uses and disclosures of your PHI

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.

Right to Inspect and Copy – You have the right to inspect or obtain a copy (or both) of PHI. Records must be requested in writing and release of information must be completed. Please make your request well in advance and allow 2 weeks to receive the copies.

Right to Amend – If you believe the information in your records is incorrect and/or missing important information, you can ask us to make certain changes, also known as amending, to your health information. You have to make this request in writing.

Right to a Copy of This Notice – If you received the paperwork electronically, you have a copy in your email. If you completed this paperwork in the office at your first session a copy will be provided to you per your request or at any time.

Right to an Accounting – You generally have the right to receive an accounting of disclosures of PHI regarding you. On your request, I will discuss with you the details of the accounting process.

Right to Terminate – You have the right to terminate therapeutic services with me at any time without any legal or financial obligations other than those already accrued.

Dogberry Tree OT