Ted Riskin, LCSW
81 Log Gap Rd
Fairview, NC 28730
828-338-5020
tedrisk@gmail.com
NOTICE OF PRIVACY PRACTICES FOR PROTECTED HEALTH INFORMATION
THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED
AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
Effective date: September 1, 2021
If you consent, the provider that you will be seeing is permitted by federal privacy laws to make uses and disclosures of your health information for purposes of treatment, payment, and health care operations. Protected Health Information (PHI) is the information we create and obtain in providing our services to you. Such information may include documenting your symptoms, examination, test results, diagnosis, treatment, and applying to your insurance plan for future care or treatment. It also includes billing documents for those services. Appropriate authorization will be obtained from you to release your PHI.
Examples of uses of your health information for treatment purposes are:
The provider obtains treatment information about you, and records it in a health record to be used by the health care provider.
During the course of your treatment, the provider determines that he/she will need to consult with another specialist, such as your primary care physician, a psychiatrist, or another professional. With your permission, the provider will share the information with such specialists and obtain their input.
Examples of use of your health information for payment purposes:
The provider submits a request for payment to your health insurance company. The health insurance company requests information from us regarding services rendered. We will provide that information to them about you and the care you receive so they can process your claims.
We verify insurance coverage prior to your first appointment and obtain prior authorization and pre-certification when required to do so by your policy coverage.
An example of use of your health information for health care operations:
We may have Business Associates such as billing services, bookkeepers, etc. who may have access to your PHI when they are preparing our routine financial statements or entering payments from insurance companies.
Your health information rights:
The health record and billing records we maintain are the physical property of this office. The information in it, however, belongs to you. You have a right to:
Request a restriction on certain uses and disclosures of your PHI by delivering the request in writing to our office. We are not required to grant the request, but we will comply with any request granted.
Obtain a paper copy of this Notice of Privacy Practices for PHI by making a request at our office.
Request that you be allowed to inspect and receive a copy of your health record and billing record. You may exercise this right by delivering the request in writing to our office.
Appeal a denial of access to your PHI except in certain circumstances.
Request that your health care record be amended to correct incomplete or incorrect information by delivering a written request to our office.
File a statement of disagreement if your amendment is denied, and require that the request for amendment and the denial be attached in all future disclosures of your protected health information.
Obtain an accounting of disclosures of your PHI as required to be maintained by law by delivering a written request to our office. The accounting will not include internal uses of information for treatment, payment, or operations, disclosures made to you or made at your request.
Request that communication of your PHI be made by alternative means or at an alternative location by delivering the request in writing to our office.
Revoke any authorizations that you made previously to use or disclose information except to the extent information or action has already been taken by delivering a written revocation to our office.
You have the right to review this Notice before signing the consent authorizing use and disclosure of your protected health information for treatment, payment, and health care operations purposes.
If you want to exercise any of the above rights, please contact your provider during normal business hours. The provider will provide you with assistance on the steps to take to exercise your rights.
Our Responsibilities
The provider is required to:
Maintain the privacy of your PHI as required by law.
Provide you with a notice as to our duties and privacy practices as to the information we collect and maintain about you.
Abide by the terms of this Notice.
Notify you if we cannot accommodate a requested restriction or request.
Accommodate your reasonable requests regarding methods to communicate health information to you.
We reserve the right to amend, change, or eliminate provisions in our privacy practices and access practices and to enact new provisions regarding the protected health information we maintain. If our information practices change, we will amend our Notice to reflect these changes. You are entitled to receive a revised copy of the Notice by calling or requesting a copy of our Notice or by visiting the office to obtain a copy.
To Request Information or File a Complaint
If you have questions, would like additional information, or want to report a problem about the handling of your information, you may contact your provider: Ted Riskin, LCSW at (973) 785-1938.
Additionally, if you believe your privacy rights have been violated, you may file a written complaint at the office by delivering the written complaint to: Ted Riskin, LCSW at 271 Rt 46W #C-110, Fairfield, NJ 07004.
You may also file a complaint by mailing or e-mailing it to the U.S. Secretary of Health and Human Services. The Provider cannot, and will not, retaliate against you for filing a complaint with the Secretary. We cannot, and will not, require you to waive the right to file a complaint with the Secretary of Health and Human Services (HHS) as a condition of receiving treatment from our office.
Other Uses and Disclosures
Notification: Unless you object, we may use or disclose your protected health information to notify, or assist in notifying, a family member, personal representative, or other persons responsible for your care, about your location, about your general condition, or your death.
Communication with family: Using our best judgment, we may disclose to a family member, other relative, close personal friend, or any other person you identify, health information relevant to that person's involvement in your care or in payment for such care if you do not object or in an emergency.
Disaster relief: We may use and disclose your protected health information to assist in disaster relief efforts.
Funeral Directors / Coroners: We may disclose your protected health information to funeral directors or coroners consistent with applicable law to allow them to carry out their duties.
Appointments and Scheduling: Unless you object, we may contact you to provide you with appointment reminders or to notify you of scheduling changes at the phone numbers that you provide to us.
Uses and Disclosures Without Consent or Authorization
Law enforcement: We may disclose your protected health information for law enforcement purposes as required by law, such as when required by a court order, or in cases involving felony prosecutions, or to the extent an individual is in the custody of law enforcement.
Abuse and Neglect: We may disclose your protected health information to public authorities as allowed by law to report abuse or neglect of children or vulnerable adults (disabled or elderly).
Duty to Warn: To avert a serious threat to health or safety, we may disclose your protected health information consistent with applicable laws to prevent or lessen a serious, imminent threat to the health or safety of a person or the public.
Workers Compensation: If you are seeking compensation through Workers Compensation, we may disclose your protected health information to the extent necessary to comply with laws relating to Workers Compensation.
Public Health: As required by law, we may disclose your protected Health information to public health or legal authorities charged with preventing or controlling disease, injury, or disability.
Health Oversight: Federal law allows us to release your protected health information to appropriate health oversight agencies or for health oversight activities. If a complaint against a provider is filed, the New Jersey Board of Health has the authority to subpoena confidential health information.
Judicial/Administrative Proceedings: We may disclose your protected health information in the course of any judicial or administrative proceeding as allowed or required by law, with your consent, or as directed by a proper court order.
For Specialized Governmental Functions: We may disclose your protected health information for specialized government functions as authorized by law such as to Armed Forces personnel, for national security purposes, or to public assistance program personnel.
Other Uses: Other uses and disclosures in addition to those identified in this Notice will be made only as otherwise authorized by law or with your written authorization and you may revoke that authorization as previously stated.
By submitting I acknowledge that I have read the Notice of Privacy Practices and can print a copy below for my records if desired.
Ted Riskin, LCSW
81 Log Gap Rd
Fairview, NC 28730
828-338-5020
tedrisk@gmail.com
Fee Agreement
If your doctor is like most, you probably wait quite a long time in his or her waiting room. By stacking patients in the waiting room, the doctor is able to see another patient if you happen to miss your appointment.
When we make an appointment, I am reserving that block of 55 minutes specifically for you. Typically, I will have other appointments scheduled around yours. If you do not come, I lose the use of the time that we reserved. Even if you have insurance, the insurance company will not pay for the missed session. Therefore, I am asking you to agree to pay $45 for a missed session.
If you need to cancel an appointment and give me 24 hours notice, you will not be responsible for the fee. If you give me less than 24 hours notice, I will rebook your time if possible. If I am able to do so, you will not be responsible for the fee.
Please communicate all cancellations and scheduling requests via the email above. The phone number does not receive texts.
When you do cancel a session with 24 hours notice, often there will have been other people who were inconvenienced because they would have liked to use that time. And even with notice, it is not always possible for me to rebook the time. So please try to minimize canceled sessions; if they happen too frequently I will be unable to continue scheduling appointments with you.
I understand the above fee agreement and have received a copy. In addition, if I am paying only my coinsurance at sessions, I agree to forward any insurance money received to Ted Riskin.
By submitting I acknowledge that I have read and understand the Fee Agreement and can print a copy for my records if desired.