HIPPA Notice

New York State Notice Form

Notice of Psychologists’ Policies and Practice 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  Operation. 

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 health care. Examples of payment are when I disclose your PHI to your health insurance carrier to obtain reimbursement for your health care or to determine eligibility or coverage.

  • Health Care Operations are activities that relate to the performance and operations of my practice. Examples of health care operations are quality assessment and improvement activities, business related matters, such as audits and administrative services, case management and care coordination.

  • “Use” applies only to activities within my office (office, clinic, practice, utilizing examining, and analyzing information.

  • “Disclosure” applies to activities outside of my (office, clinic, practice, or providing access to information about you to other parties).