Medicare New Client Paperwork

Please only include phone numbers where you prefer to be contacted and where we may leave a message.

The privacy of your personal information is important to West County Psychological Associates (WCPA). WCPA will maintain the privacy of your information and will not disclose your information to others unless you tell WCPA to do so, or unless the law authorizes or requires WCPA to do so.

A federal law commonly known as HIPAA requires that WCPA take additional steps to keep you informed about how WCPA may use information that is gathered in order to provide health care services to you. As part of this process, WCPA is required to provide you with the attached Notice of Privacy Practices and to request that you sign the written acknowledgement that you received a copy of the Notice. The Notice describes how WCPA may use and disclose your protected health information to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law. This Notice also describes your rights regarding personal information WCPA maintains about you and a brief description of how you may exercise these rights.

If you have any questions about this Notice please contact WCPA’s Director, Dr. Mary Fitzgibbons, at (314) 275-8599.

WCPA is required by applicable federal and state law to maintain the privacy of your health information. It is also required to give you this Notice about privacy practices, legal obligations, and your rights concerning your health information (“Protected Health Information” or “PHI”). It must follow the privacy practices that are described in this Notice (which may be amended from time to time).

For more information about privacy practices, or for additional copies of this Notice, please contact WCPA using the information listed in Section II G of this notice.

I. USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION (PHI)

A. Permissible Uses and Disclosures without Your Written Authorization
WCPA may use and disclose PHI without your written authorization, excluding Psychotherapy Notes as described in Section II, for certain purposes as described below. The examples provided in each category are not meant to be exhaustive, but instead are meant to describe the types of uses and disclosures that are permissible under federal and state law.

1. Treatment: WCPA may use and disclose PHI in order to provide treatment to you. For example, WCPA may use PHI to diagnose and provide counseling service to you. We may also disclose your information in order to remind you of appointment times. We may disclose your information to any family members or significant others that you voluntarily decide to bring to and include in a therapy session. We may disclose your PHI, with the exception of identifying information, during professional clinical supervision and/or consultation, in order to ethically provide you the highest quality services.
2. Payment: WCPA may use or disclose PHI so that services you receive are appropriately billed and payment is collected. By way of example, it may disclose PHI to permit your health plan to take certain actions before it approves or pays for treatment services.
3. Health Care Operations: WCPA may use and disclose PHI in connection with our health care operations, including quality improvement activities, training programs, accreditation, certification, licensing or credentialing activities.
4. Required or Permitted by Law: WCPA may use or disclose PHI when it is required or permitted to do so by law. For example, it may disclose PHI to appropriate authorities if it reasonably believes that you or a child are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. In addition it may disclose PHI to the extent necessary to avert a serious threat to your health or safety or the health or safety of others. Other disclosures permitted or required by law include the following: disclosures for public health activities; health oversight activities including disclosures to state or federal agencies authorized to access PHI; disclosures to judicial and law enforcement officials in response to a court order or other lawful process; disclosures for research when approved by an institutional review board; and disclosures to military or national security agencies, coroners, medical examiners, and correctional institutions or otherwise as authorized by law.

B. Uses and Disclosures Requiring Your Written Authorization

1. Psychotherapy Notes: Notes recorded by your clinician documenting the contents of a counseling session with you (“Psychotherapy Notes”) will be used only by your clinician and will not otherwise be used or disclosed without your written authorization.
2. Marketing Communications: WCPA will not use your health information for marketing or fundraising communications without your written authorization. You have the right to opt out of any marketing or fundraising communications that you choose not to receive.
3. Other Uses and Disclosures: Uses and disclosures other than those described in Section I.A. above will only be made with your written authorization. For example, you will need to sign an authorization form before WCPA can send PHI to your life insurance company, to a school, or to your attorney. You may revoke any such authorization at any time.

II. YOUR INDIVIDUAL RIGHTS

1. Right to Inspect and Copy. You may request access to your medical record and billing records maintained by WCPA in order to inspect and request copies of the records. All requests for access must be made in writing. Under limited circumstances, WCPA may deny access to your records. WCPA may charge a fee for the costs of copying and sending you any records requested. If you are a parent or legal guardian of a minor, please note that certain portions of the minor’s medical record may not be accessible to you, in accordance with state law. You have the right to an electronic communication of any records that WCPA keeps electronically.
2. Right to Alternative Communications. You may request, and WCPA will accommodate, any reasonable written request for you to receive PHI by alternative means of communication or at alternative locations.
3. Right to Request Restrictions. You have the right to request a restriction on PHI used for disclosure for treatment, payment or health care operations. You must request any such restriction in writing addressed to the Privacy Officer as indicated below. WCPA is not required to agree to any such restriction you may request. One exception is that, if you self-pay at WCPA, you may request that we not disclose these services to your health insurance company and WCPA is obligated to honor that request.
4. Right to Accounting of Disclosures or Breaches. Upon written request, you may obtain an accounting of disclosures of PHI made by WCPA after October 1, 2013. This right is subject to restrictions and limitations. You also have the right to be notified by WCPA if a privacy breach of your PHI has occurred. If such a breach occurred, you would be notified within a reasonable time.
5. Right to Request Amendment. You have the right to request that WCPA amend your health information. Your request must be in writing, and it must explain why the information should be amended. WCPA may deny your request under certain circumstances.
6. Right to Obtain Notice. You have the right to obtain a paper copy of this Notice by submitting a request to the Privacy Officer at any time.
7. Questions and Complaints. If you desire further information about your privacy rights, or are concerned that WCPA has violated your privacy rights, you may contact the Privacy Officer, Director Mary Fitzgibbons, Ph.D., at (314) 275-8599. You may also file written complaints with the Director, Office for Civil Rights of the U.S. Department of Health and Human Services. WCPA will not retaliate against you if you file a complaint with the Director or the Privacy Officer.

III. EFFECTIVE DATE AND CHANGES TO THIS NOTICE

1. Effective Date. This Notice is effective on October 1, 2013.
2. Changes to this Notice. WCPA may change the terms of this Notice at any time. If WCPA changes this Notice, it may make the new notice terms effective for all PHI that it maintains, including any information created or received prior to issuing the new notice. If WCPA changes this Notice, it will post the revised notice in the waiting area of the office and on our website. You may also obtain any revised notice by contacting the Privacy Officer.

This Form is educational only, does not constitute legal advice, and covers only federal, not state, law.

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

Giving you the best possible service with consideration for your well-being is of utmost importance to us. The following is information concerning missed appointments and late cancellations.

Should you need to cancel an appointment, we require 24 hours notice. Those sessions cancelled without 24 hours notice, other than those cancelled due to emergency, will be charged to you. In order to cancel, you MUST contact your therapist directly or the WCPA office via our office phone number and leave a message for your therapist on their private office voicemail. The office number is 314.275.8599. Cancellations made via email, text, or verbal message to a secretary may still be charged. Thank you for your cooperation.

Payments are covered by Medicare and other supplemental insurance. However, missed appointments are not covered by Medicare. Therefore, clients will be responsible for payment for missed appointments.