Notice of Privacy Practices and Terms of Service for David Steinberg, PhD
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.
This practice is required by law to maintain the privacy of your health information and to provide you with notice of its legal duties and privacy practices with respect to your health information. If you have questions about any part of this notice or if you want more information about the privacy practices please contact:
David Steinberg, PhD
(212) 721-1379 or (215) 253-4473
Effective Date of This Notice: April 14th 2003.
As per the Health Insurance Portability and Accountability Act of 1996 (HIPAA), the following statement outlines David Steinberg, PhD's policy on client privacy. As of April 14, 2003, this office has implemented and is in compliance with the HIPAA privacy regulations designed to protect patient's personal mental health information. David Steinberg, PhD maintains contracts with his business associates that essentially bind the business associates to the HIPAA regulations. Business associates are defined as individuals who receive health information from David Steinberg, PhD or on behalf of David Steinberg, PhD. Examples include a copy center, a contracted phone answering service, payment collection services, an accountant reviewing books, auditors, quality assurance/utilization review services, or other contracted services that might interact with protected health information.
Protected health information includes information:
- about a person's health, health care, or payment of health care (the term health includes mental health and behavioral health issues)
- that identifies a person
- created or received by a covered health care plan or provider
Note : All medical records or other individually identifiable health information held or disclosed by David Steinberg, PhD in any form (electronically, on paper, or orally) are covered by the final Health Insurance Portability and Accountability Act of 1996 (HIPAA) regulation.
How is this information protected?
Protected health information may not be disclosed by David Steinberg, PhD without your informed and voluntary written consent or authorization. David Steinberg, PhD is required to obtain your consent for use or disclosure of your information for purposes of health care treatment, payment, and operations. Disclosure must be limited to the minimum amount necessary for the purposes of disclosure, with the exception of transferring records for treatment, when providers need access to the full record to ensure quality care. Your authorization is required for any other type of disclosure. Health care providers may condition treatment on obtaining client consent of protected health information for the purposes of treatment, payment, and health care operations. Similarly, health plans and health care clearinghouses also may condition enrollment on your provision of a consent to disclose protected health information for the purposes of treatment, payment, and health care operations.
David Steinberg, PhD will use and disclose your health care information to seek reimbursement for services rendered to you and members of your household. In this process, other parties may have access to the information you give me.
In this context, these parties include:
- The insurance organizations involved in your care.
- If one is required, the collection agency David Steinberg, PhD uses to collect unpaid balances.
- Other firms that become involved in the process of processing or reviewing payment activities.
- Let it be clear that as little information as is possible will be shared with any payment organization.
What are your rights under these regulations?
- You have a right to gain access to your medical records. You are entitled to see and copy your records and request amendments. A history of disclosures of protected health information must be made available to you on your written request. David Steinberg, PhD may charge a fee for this service.
- You have a right to request a restriction on the use and disclosure of your protected health information for the purposes of treatment, payment, or health care operations.
- David Steinberg, PhD is required to provide you with a clear, written explanation of how your protected health information can be used and disclosed.
There are a number of exceptions under the HIPAA regulations that allow for disclosure of client's protected health information without client consent or authorization.
Some permitted HIPAA disclosures are:
- disclosures required by law.
- permitted disclosures for public health activities (such as reporting diseases, collecting vital statistics, etc)
- disclosure about victims of abuse, neglect or domestic violence.
- health oversight activities.
- disclosures for judicial or administrative proceedings
- disclosures for law enforcement purposes
- use and disclosure for research purposes
- disclosures to avert a serious threat to health or safety.
The HIPAA regulations are permissive,which means that these are the circumstances under the regulations in which mental health care providers are permitted to disclose protected health information without client consent or authorization. However, David Steinberg, PhD will not under any circumstances disclose your information for research without your signed consent.
How do the HIPAA requirements apply to mental health records?
- Psychotherapy notes are accorded special privacy protections under this regulation. Ordinarily, a written client consent is required before psychotherapy notes can be disclosed to anyone.
- A health plan may not condition a client's enrollment or eligibility on the provision of the client's authorization or consent for disclosure of psychotherapy notes.
- Psychotherapy notes are excluded from the provision that gives clients the right to see and copy their health information.
How are psychotherapy notes defined?
- Psychotherapy notes are defined in the regulation as notes recorded (in any medium) by a health care provider who is a mental health professional documenting or analyzing the contents of conversation during a private counseling session or a group, joint, or family counseling session and that are separated from the rest of the individual's medical record (emphasis added).
- Excluded from the definition of psychotherapy notes are medication prescription and monitoring, counseling session start and stop times, modalities and frequencies of treatment furnished, results of clinical tests, and any summary of the following items: diagnosis, functional status, treatment plan, symptoms, prognosis, and progress to date.
Psychotherapy notes may be disclosed without consent or authorization under the following situations without client's consent or authorization:
- when needed to defend a lawsuit against the therapist by the individual who is the subject of the notes;
- to HHS when required for enforcement of the privacy rule;
- when required by law;
- when needed for oversight of the provider who created the notes;
- to a coroner or medical examiner;
- when needed to avert a serious and imminent threat to health or safety.
- Unlike other health records, psychotherapy notes are not subject to disclosure to individuals.
Other than it is written in this Notice of Privacy Practices, David Steinberg, PhD will not use or disclose your health information without your written authorization. If you do authorize David Steinberg, PhD to use or disclose your health information for another purpose, you may revoke your authorization in writing at any time.
Changes to this Notice of Privacy Practices
David Steinberg, PhD reserves the right to amend this Notice of Privacy Practices at any time in the future. Until such amendment is made, the practice is required by law to comply with this Notice.
Complaints
You have the right to file a complaint with David Steinberg, PhD about his adherence to these policies.
(i) Your complaint should be directed to David Steinberg, PhD.
(ii) You can either write a letter addressed to David Steinberg, PhD, or complete and submit the appropriate form available from this office. Additional copies are available separately.
You have the right to file a complaint with the Secretary of Health and Human Services.
(i) You should write a letter describing your concerns.
(ii) The letter should be addressed as follows:
Secretary of Health and Human Services
The U.S. Department of Health Human Services
200 Independence Avenue, S.W.
Washington, D.C. 20201
David Steinberg, PhD
617 West Cliveden Street 371 Amsterdam Avenue
Philadelphia, PA. 19119 New York, New York 10024
215 253 4473 212-721-1379
Terms of Service
The terms of service are to be arranged and agreed upon by David Steinberg, PhD and the recipient of his services. As a general rule of thumb, patients are expected to attend all sessions as they are scheduled. Cancellations of sessions by patients must be made no later than 72 hours in advance, or patients will be required to pay in full for the canceled session. Individual consideration will be made in the event of a medical or family emergency. David Steinberg, PhD will make all attempts possible to reschedule missed sessions for later in the week.
I have read, and have been given a copy of the above privacy policy and terms of service. I understand that I have the right to ask questions until I fully understand the implications of this policy and the terms of service. By signing this document I give David Steinberg consent to begin my evaluation and treatment.
Print Name__________________________________ Date of Birth:______________________
Address:_____________________________________________________________________
City:_________________________________ State:__________________________________
Insurance Company___________________________Insurance Plan:____________________
Insurance ID#_________________________________________________________________
Social Security #_______________________________________________________________
Signature______________________________
Witness:__________________________________
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