Welcome to KS NP in Psychiatry and Family Health. Your agreement to the following terms and conditions is required for you/your child to receive professional services from us.
This notice went into effect on February 13,2024 NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW HEALTH INFORMATION MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
I.OUR PLEDGE REGARDING HEALTH INFORMATION: KS NP Psychiatry and Family Health understand that health information about you and your health care is personal. KS NP Psychiatry and Family Health are committed to protecting health information about you. KS NP Psychiatry and Family Health create a record of the care and services you receive from us. We need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all the records of your care generated by this mental health care practice. This notice will tell you about the ways in which we may use and disclose health information about you. We also describe your rights to the health information we keep about you, and describe certain obligations we have regarding the use and disclosure of your health information. KS NP Psychiatry and Family Health are required by law to: • Make sure that protected health information (“PHI”) that identifies you is kept private. • Give you this notice of KS NP Psychiatry and Family Health legal duties and privacy practices with respect to health information. • Follow the terms of the notice that is currently in effect. • KS NP Psychiatry and Family Health can change the terms of this Notice, and such changes will apply to all information we have about you. The new Notice will be available upon request.
II HOW KS NP Psychiatry and Family Health MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU: The following categories describe different ways that KS Family Health NP uses and disclose health information. For each category of uses or disclosures we will explain what we mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all the ways we are permitted to use and disclose information will fall within one of the categories. For Treatment Payment, or Health Care Operations: Federal privacy rules (regulations) allow health care providers who have direct treatment relationship with the patient/client to use or disclose the patient/client’s personal health information without the patient’s written authorization, to carry out the health care provider’s own treatment, payment, or health care operations. KS NP Psychiatry and Family Health may also disclose your protected health information for the treatment activities of any health care provider. This too can be done without your written authorization. For example, if a clinician were to consult with another licensed health care provider about your condition, we would be permitted to use and disclose your personal health information, which is otherwise confidential, to assist the clinician in diagnosis and treatment of your mental health condition. Disclosures for treatment purposes are not limited to the minimum necessary standard. Because therapists and other health care providers need access to the full record and/or full and complete information to provide quality care. The word “treatment” includes, among other things, the coordination and management of health care providers with a third party, consultations between health care providers and referrals of a patient for health care from one health care provider to another. Lawsuits and Disputes: If you are involved in a lawsuit, KS Family Health NP may disclose health information in response to a court or administrative order. KS Family Health NP may also disclose health information about your child in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.
III. CERTAIN USES AND DISCLOSURES REQUIRE YOUR AUTHORIZATION: 1. Psychotherapy Notes. KS NP Psychiatry and Family Health do keep “psychotherapy notes” as that term is defined in 45 CFR § 164.501, and any use or disclosure of such notes requires your Authorization unless the use or disclosure is: a. For our use in treating you. b. For our use in training or supervising mental health practitioners to help them improve their skills in group, joint, family, or individual counseling or therapy. c. For our use in defending myself in legal proceedings instituted by you. d. For use by the Secretary of Health and Human Services to investigate our compliance with HIPAA. e. Required by law and the use or disclosure is limited to the requirements of such law. f. Required by law for certain health oversight activities pertaining to the originator of the psychotherapy notes. g. Required by a coroner who is performing duties authorized by law. h. Required to help avert a serious threat to the health and safety of others. 2. Marketing Purposes. We will not use or disclose your PHI for marketing purposes. 3. Sale of PHI. We will not sell your PHI in the regular course of our business.
IV. CERTAIN USES AND DISCLOSURES DO NOT REQUIRE YOUR AUTHORIZATION. Subject to certain limitations in the law, KS NP Psychiatry and Family Health can use and disclose your PHI without your Authorization for the following reasons: 1. When disclosure is required by state or federal law, and the use or disclosure complies with and is limited to the relevant requirements of such law. 2. For public health activities, including reporting suspected child, elder, or dependent adult abuse, or preventing or reducing a serious threat to anyone’s health or safety. 3. For health oversight activities, including audits and investigations. 4. For judicial and administrative proceedings, including responding to a court or administrative order, although my preference is to obtain an Authorization from you before doing so.5. For law enforcement purposes, including reporting crimes occurring on my premises. 6. To coroners or medical examiners, when such individuals are performing duties authorized by law. 7. For research purposes, including studying and comparing the mental health of patients who received one form of therapy versus those who received another form of therapy for the same condition. 8. Specialized government functions, including, ensuring the proper execution of military missions; protecting the President of the United States; conducting intelligence or counterintelligence operations; or, helping to ensure the safety of those working within or housed in correctional institutions. 9. For workers’ compensation purposes. Although our preference is to obtain an Authorization from you, we may provide your PHI in order to comply with workers’ compensation laws. 10 Appointment reminders and health related benefits or services. We may use and disclose your PHI to contact you to remind you that you have an appointment with us. We may also use and disclose your PHI to tell you about treatment alternatives, or other health care services or benefits that we offer. V. CERTAIN USES AND DISCLOSURES REQUIRE YOU TO HAVE THE OPPORTUNITY TO OBJECT. 1. Disclosures to family, friends, or others. KS Family Health NP may provide your PHI to a family member, friend, or other person that you indicate is involved in your care or the payment for your health care, unless you object in whole or in part. The opportunity to consent may be obtained retroactively in emergency situation.
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YOU HAVE THE FOLLOWING RIGHTS WITH RESPECT TO YOUR PHI: 1. The Right to Request Limits on Uses and Disclosures of Your PHI. You have the right to ask us not to use or disclose certain PHI for treatment, payment, or health care operations purposes. We are not required to agree to your request, and we may say “no” if we believe it would affect your health care. 2. The Right to Request Restrictions for Out-of-Pocket Expenses Paid for In Full. You have the right to request restrictions on disclosures of your PHI to health plans for payment or health care operations purposes if the PHI pertains solely to a health care item or a health care service that you have paid for out-of-pocket in full. 3. The Right to Choose How KS In Psychiatry and Family Health sends PHI to You. You have the right to ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address, and we will agree to all reasonable requests. 4. The Right to See and Get Copies of Your PHI. Other than “psychotherapy notes,” you have the right to get an electronic or paper copy of your medical record and other information that we have about you. We will provide you with a copy of your record, or a summary of it, if you agree to receive a summary, within 30 days of receiving your written request, and we may charge a reasonable, cost-based fee for doing so. 5. The Right to Get a List of the Disclosures We Have Made. You have the right to request a list of instances in which KS NP in Psychiatry and Family Health has disclosed your PHI for purposes other than treatment, payment, or health care operations, or for which you provided us with an Authorization. We will respond to your request for an accounting of disclosures within 60 days of receiving your request. The list we will give you will include disclosures made in the last six years unless you request a shorter time. We will provide the list to you at no charge, but if you make more than one request in the same year, we will charge you a reasonable cost-based fee for each additional request. 6. The Right to Correct or Update Your PHI. If you believe that there is a mistake in your PHI, or that a piece of important information is missing from your PHI, you have the right to request that we correct the existing information or add the missing information. We may say “no” to your request, but we will tell you why in writing within 60 days of receiving your request. 7. The Right to Get a Paper or Electronic Copy of this Notice. You have the right get a paper copy of this Notice, and you have the right to get a copy of this notice by e-mail. And, even if you have agreed to receive this Notice via e-mail, you also have the right to request a paper copy of it. Acknowledgement of Receipt of Privacy Notice Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), you have certain rights regarding the use and disclosure of your protected health information. By checking the box below, you are acknowledging that you have received a copy of HIPAA Notice of Privacy Practices. By typing my signing below, I hereby certify that I have read, understood, and agree to the provision of psychiatric services by KS NP Psychiatry and Family Health.
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PRACTICE POLICIES Practice Policies for Booking, Cancellation, No-Show, Payments, Etc. APPOINTMENTS KS in Psychiatry and Health NP only offers tele-health appointments either by video conferencing or telephone and In person appointments are also offered on specific days. APPOINTMENT BOOKINGS To reserve an appointment with our providers, you must provide credit card information that will be stored in your secure record. Your credit card will automatically be charged as follows: (1) on the morning of your scheduled appointment, (2) upon cancellation or re-scheduling of an appointment within 24 hours of appointment time, (3) upon late or no-show for appointment. APPOINTMENT LENGTH Please select the appropriate length of appointment you require based on your personal needs. Should you require additional time at the end of your session, your provider will try to accommodate you if their schedule allows, but you will be charged for the additional time in accordance with our service pricing. APPOINTMENT INTERVALS Your provider will discuss the appropriate appointment interval for your unique and individual needs. Should you require psychiatric medication management, you are required to see your provider at least once per month for ongoing medication management. APPOINTMENT FEES (Does not apply to clients using insurance with our in-network providers.) You agree to pay professional fees as follows: Psychiatric Evaluation 60 mins $300, Psychiatric Follow up 45 mins $220, Psychiatric Follow up 30 minutes $150. Rates are subject to change and will be updated on our website.
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FORMS & DOCUMENTS For your initial visit and consultation, you will be required to complete a package of online intake forms and consents. Completion of intake forms is required 48 hours in advance of your appointment time. If you do not see your provider for a period of 90 days or longer, you will be required to book a new initial consultation appointment and complete all your initial intake forms again. In this event, there is no guarantee that you will be seen by your original provider at KS Psychiatry and Family Health. You may be placed on a wait list depending on availability.
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ACCOMMODATION LETTERS & FORMS If you require a form asking for accommodation at work, school, or leave of absence or any kind, KS Family Health NP reserve the right to refuse such forms if they disagree with the request due to their clinical findings. If they provider is open to filling out the forms an appointment time must be booked appropriate for completing the letter or form in its entirety.
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CANCELLATIONS & RE-SCHEDULING Please remember to cancel or reschedule at least 24 hours in advance. You will be charged a $75 fee for a cancellation or re-scheduling within 24 hours of your appointment time. This is necessary because a time commitment is made to you and is held exclusively for you.
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UNIVERSITY AFFILIATIONS AND INTERNS KS NP Psychiatry and Family Health is an approved clinical site for multiple New York based universities. In our commitment to nursing education and affiliated universities, our providers often supervise intern PMHNPs who are pursuing graduate work and are in process of earning their psychiatric nurse practitioner certificates. Therefore, there may come a time that you will have contact with or will work directly with student intern PMHNPs. You reserve the right to request to not work with a student/intern. KS NP Psychiatry and Family Health will do its best to meet your request depending on provider availability.
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LATE & NO-SHOWS If you are late for a session, we may only be able to see you for the time remaining in your appointment or may not be able to accommodate you at all depending on your tardiness, your session length, and our commitment to other clients. In any case, if you are late or no-show to appointments, you will be charged the full cost of the entire scheduled appointment.
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TELEPHONE & TEXT ACCESSIBILITY BETWEEN APPOINTMENTS You may contact KS NP In Psychiatry and Family Health by phone, email, or text message. You and your provider are also expected to communicate directly regarding your care. You may contact your provider via phone, text, or email should you have any questions or concerns pertaining to your treatment. Your provider may not answer immediately and if you need urgent assistance, we encourage you to also contact our main office. If you require emergency attention, call 911 or attend a local emergency room.
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PRESCRIPTION REFILLS at KS In Psychiatry and Family Health providers do not respond to pharmacy refill requests. It is up to you to contact your provider when you require a refill on your medications. It is expected that you and your provider meet consistently and regularly for your prescriber to provide medication management. KS NP In Psychiatry and Family Health will not provide early refills on controlled substances. Additionally, controlled substances require that the client be assessed at each refill.
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SOCIAL MEDIA AND TELECOMMUNICATION Due to the importance of your confidentiality and the importance of minimizing dual relationships, KS NP IN Psychiatry and Family Health providers do not accept friend or contact requests from current or former clients on their personal social networking sites (Facebook, Instagram, etc). We believe that adding clients as friends or contacts on these sites can compromise your confidentiality and our respective privacy. It may also blur the boundaries of the therapeutic relationship.
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MINORS If you are a minor, your parents may be legally entitled to some information about your therapy. Your provider will discuss with you and your parents’ what information is appropriate for them to receive and which issues are more appropriately kept confidential.
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TERMINATION Ending relationships can be difficult. Therefore, it is important to have a termination process to achieve some closure. The appropriate length of the termination depends on the length and intensity of the treatment. Your provider may terminate treatment after appropriate discussion with you and a termination process if they determine that the psychotherapy is not being effectively used or if you are in default on payment. Orenda Psychiatry will not terminate the therapeutic relationship without first discussing and exploring the reasons and purpose of terminating. If therapy is terminated for any reason or you request another provider, you may request another provider by contacting our front office. Should you fail to schedule an appointment within 90 days, unless other arrangements have been made in advance, for legal and ethical reasons, we must consider the professional relationship discontinued.
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Informed Consent for Psychiatric Treatment Make sure you read all the important information below. Only use our services if you have read this information and have made an informed decision that our services are appropriate for you. BACKGROUND INFORMATION Our psychiatric team is composed of psychiatric mental health professionals. We are a telemedicine psychiatry practice and are required by law to perform an assessment prior to medications being prescribed. We require a video appointment to meet our legal requirement. We are not a pharmacy and we do not send prescriptions outside of the U.S. EMERGENCIES I understand that in the event of an emergency, I should dial 911 or go to the nearest emergency department. I understand that Orenda Psychiatry is not to be used in the event of a medical or psychiatric emergency. WHEN DUTY OF CARE BEGINS, I understand that my provider will take responsibility for my care after I have completed all the required health questions and forms, had an initial evaluation, and subsequently determined to be a good candidate for psychiatric services with the provider who performs my initial assessment. I understand that the duty of care does not begin at the point of me completing intake questions, scheduling an appointment, making payment, or starting a scheduled session. It begins when the provider accepts the duty of care. I understand that the provider has the right to refuse responsibility for my care if they determine that I am not a good candidate for this service. I understand that duty of care is not established by making a request for treatment, scheduling an appointment, making a payment, or starting a video session. I understand that sending a message through the website or the secure messaging system does not establish a patient-provider relationship. I understand that there may be a delay or number of days before my request for treatment or my messages are viewed. I understand that content found on the website is not medical or psychiatric advice.
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RISKS AND BENEFITS OF USING OUR TELE-PSYCHIATRY SERVICE I understand that currently video conferencing technology will be used and that I will not have the opportunity to meet with my provider in person at their location. I understand that potential benefits of Telehealth communication include easier access to care and the convenience of meeting from a location of my choosing. I understand that there are potential risks to tele-health, including interruptions, technical difficulties, and unauthorized access. I understand that I or my provider can end the consult/visit if it is felt that the connection is not adequate. I understand that I will not have an in-person consultation or an in person physical exam. This might prevent the identification of a medical or psychiatric condition that needs further investigation or immediate treatment. I understand that if I have any questions relating to my care that are not urgent, I can message my provider through the secure messaging system or contact them by email or phone. I understand that my messages may not be viewed or responded to for several days. To maintain confidentiality, I will not share my tele-health appointment link with anyone unauthorized to attend the appointment. IMPORTANCE OF FULLY AND TRUTHFULLY ANSWERING ALL QUESTIONS I understand that the information I provide will be used to determine my treatment. I understand that the safety and appropriateness of treatment prescribed will rely on the accuracy of information I share with my provider. I understand that my provider will consider information I share to be true and complete, including my age, gender, sex, and all answers to my health questions. I agree to provide a copy of a federally issued photo identification card or passport. I understand that if I provide information that is not true, complete, or accurate, that I will be at greater risk for adverse events, or for treatment that is not safe, necessary, or effective. I understand that even if I provide information that is true and complete, there are still risks to treatment.
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RISKS OF PSYCHOTROPIC MEDICATION I understand that all medications that may be prescribed or recommended by my provider, including prescriptions, over the counter medications, and herbal supplements can cause serious side effects, adverse events, severe allergic reaction, permanent disability, and death. I understand that it is my responsibility to make an informed decision and whether to agree to a treatment plan that is proposed by my provider. I understand that by accepting a treatment plan it is my responsibility to weigh the benefits against the risks of taking prescribed medication, using alternative treatment, and the option of not seeking treatment. I understand the importance of reading the manufacture’s print and warnings that come with the medicine before taking. I understand that adverse events can be caused by several things, such as an allergic reaction, side effects, or interactions with another medication that I take. I understand that adverse events can also be caused by combining prescribed medication with supplements, herbs, recreational drugs, tobacco, and alcohol. I understand that if I am a threat to myself or others, I should not use Orenda Psychiatry and instead, I should call 911 or contact the National Suicide Prevention Hotline at 1-800-2738255. I understand that the prescription medicine classes selective serotonin inhibitors (SSRIs), norepinephrine serotonin re-uptake inhibitors (SNRI) and atypical antidepressant (bupropion) are FDA approved for depression and/or anxiety and are prescribed in that manner. I understand that taking these types of medicines may cause sexual dysfunction (problems with orgasm, ejaculation, and/or erectile dysfunction), and potentially life-threatening side effects, the risk of suicidal thoughts and behavior and can cause a severe allergic reaction that can lead to disability and even death. I understand that abruptly stopping any of the treatments may cause symptoms including but not limited to anxiety, irritability, agitation, dizziness, nausea, and sensory disturbances such as the feeling of having an electric shock. I understand that as part of treatment I am required to provide an emergency contact person as well as ensuring any weapons at home are both unloaded and locked. I understand as part of treatment that my provider may require me to abstain from any alcohol or substance use including but not limited to marijuana, cocaine, and stimulants. I understand that if I am unable to satisfy these terms of treatment, I may not be an appropriate candidate for this service and may be discharged from Orenda Psychiatry. I understand that my provider has the right to terminate treatment at any time. I understand that there are alternatives to the prescription-only medicines and my provider may incorporate psychotherapy into treatment. I understand that I may be required to participate in psychotherapy with my provider for my provider to prescribe medication.
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RISKS TO ELECTRONIC HEALTH INFORMATION I understand that although KS IN Psychiatry and Heath implements administrative, physical, and technical safeguards to protect my health information, KS In Psychiatry and Health cannot guarantee the privacy and confidentiality of my health information. RISKS AND BENEFITS TO PSYCHOTHERAPY I understand that the outcome of my treatment depends largely on my willingness to engage in this process, which may, at times, result in considerable discomfort. I understand that remembering unpleasant events and becoming aware of feelings attached to those events can bring on strong feelings of anger, depression, anxiety, etc. I understand that there are no miracle cures and that there is no promise that my behavior or circumstance will change.
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CONFIDENTIALITY The session content and all relevant materials to the client’s treatment will be held confidential unless the client requests in writing to have all or portions of such content released to a specifically named person/persons. Limitations of such client held privilege of confidentiality exist and are itemized below: 1. If a client threatens or attempts to commit suicide or otherwise conducts him/her self in a way there is a substantial risk of incurring serious bodily harm. 2. If a client threatens grave bodily harm or death to another person. 3. If the therapist has a reasonable suspicion that a client or other named victim is the perpetrator, observer of, or actual victim of physical, emotional, or sexual abuse of children under the age of 18 years. 4. Suspicions as stated above in the case of an elderly person who may be subjected to these abuses. 5. Suspected neglect of the parties named in items #3 and # 4. 6. If a court of law issues a legitimate subpoena for information stated on the subpoena. 7. If a client is in therapy or being treated by order of a court of law, or if information is obtained for the purpose of rendering an expert’s report to an attorney. Occasionally the provider may need to consult with other professionals in their areas of expertise to provide the best treatment for the client. Information about the client may be shared in this context without using their name.
By singing below, I hereby certify that I have read, understood, and agree to the provision of psychiatric services by KS Family Health NP. Your copay/deductible is due at the time of your appointment. We require you to keep a credit card on file. You may use a health savings card if you have one. If you have any questions, please contact us at (718) 838-0830. Credit Card Number 4147400115113365 Credit Card Expiration (mm/yy) 10/27 CVC/security code 628 Billing Zip code 14051 By your electronic signature of this form, you authorize charges to your credit card through Square for services rendered. If you are using your insurance for your appointments, then your copay/co-insurance payment will be processed through your credit card. I authorize KS NP in Psychiatry and Family Health to charge my credit card through Square. I also agree that my credit card can be charged for any session that is not cancelled at least 48 hours prior to the scheduled session. I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify KS NP Psychiatry and Family Health in writing of any changes in my account information or termination of this authorization. I certify that I am an authorized user of this credit card and will not dispute these scheduled transactions with my bank or credit card company if the transactions correspond to the terms indicated in this authorization form. I acknowledge that credit card transactions could be linked to Protected Health Information. Please CALL or TEXT the clinic to communicate with KS NP Psychiatry and Family team member. We DO NOT use messaging system for schedule changes, medication questions or any matter that needs immediate assistance. Save our main line in your phone.
