PATIENT INFORMATIONBy providing a phone number and an email address I hereby consent to receive voicemails, phone calls and emails from NY Psychiatric Services clinics. *-RequiredPATIENT INFORMATIONDate Date Format: MM slash DD slash YYYY First Name*Last Name*E-mail* Cell Phone*Home PhoneSoc. Sec#*GenderMaleFemaleMarital StatusSingleMarriedWidowedSeperatedDivorcedBirth Date* Date Format: MM slash DD slash YYYY AgePADDING-HIDDENADDRESSStreet Name*Apartment*City*State*New YorkAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasLouisianaMaineMarylandMassachusetts[E]MichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvania[F]Rhode Island[G]South CarolinaSouth DakotaTennesseeTexasUtahVermontVirginia[H]WashingtonWest VirginiaWisconsinWyomingZip*Patient employed byOccupationBusiness AddressBusiness PhoneWhom may we thank for referring you?In case of emergency who should be notified?PhonePRIMARY INSURANCEPerson responsible for accountRelation to patientBirth Date Date Format: MM slash DD slash YYYY Soc. Sec.#Address(if different from patient's)PhoneCityStateNew YorkAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingZipPerson Responsible Employed byOccupationBusiness AddressBusiness PhoneInsurance companyContact#Group#Subscriber#Names of other dependents covered under this planADDITIONAL INSURANCEIs patient covered by additional insurance?YesNoSubscriber NameRelation to PatientBirth date Date Format: MM slash DD slash YYYY Soc. Sec.#Address(if different from patient's)PhoneCityStateNew YorkAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNebraskaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingZipSubscriber employed byBusiness PhoneInsurance companyContact #Group #Subscriber#Names of other dependents covered under this planASSIGNMENT AND RELEASEI, the undersigned certify that I (or my dependent) have insurance coverage withand assign directly to N.Y. PSYCHIATRIC SERVICES, P.C. all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for not covered services and all charges whether or not paid by insurance. I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all insurance submissions.Responsible party signatureRelationshipDate* Date Format: MM slash DD slash YYYY NEW YORK PSYCHIATRIC SERVICES, P.C.I also hereby consent to the disclosed of my health information of the following purpose: to provide diagnosis and treatment to my primary care physician for coordination of care.Date* Date Format: MM slash DD slash YYYY Primary Care Physician information:NameAddressCityStateNew YorkAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingZipPhone:REFFERAL LISTDate: Date Format: MM slash DD slash YYYY 1. How did you hear about us?InternetGoogleYahooBingYelpOnline MapsZocDoc2.Person:3.Insurance4.Other( please specify)ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICESPatient Name I have been presented with a copy of notice of privacy practices, detailing how my information may be used and disclosed as permitted under federal and state law. I understand and agree with the contents of the notice. I also hereby consent to the disclosure of my health information for the following purposes: (1) to provide my health care treatment; (2) to obtain payment for the services provided to me; and (3) to carry out ordinary health care and business operations.Patient or legal representative signatureDate* Date Format: MM slash DD slash YYYY If not signed by the patient, please indicate relationship to patient.PADDING-HIDDENNOTICE OF PRIVACY PRACTIVESEffective date of this notice is April 14, 2003THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED, DISCLOSED, AND HOW YOU CAN OBTAIN ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.INTRODUCTIONWe understand that patient’s personal information must be protected. “Protected health information” is individually identifiable health information. This information includes demographics (such as: age, address, and telephone number) and relates to your past, present, or future physical or mental health condition, and related healthcare services.ACKNOWLEDGEMENT OF RECEIPT OF THIS NOTICEYou will be asked to provide a signed acknowledgement of receipt of this notice. Our intent is to make you aware of the possible uses and disclosures of your protected health information and your privacy rights. If you refuse to sign the acknowledgement, we will continue to provide your treatment, and will use and disclose your protected health information for treatment, payment, and healthcare operations when necessary and when required by law.YOUR RIGHTS REGARDING YOUR PROTECTED HEALTH INFORMATIONYou may exercise the following rights by submitting a written request to our Privacy Officer. Please be aware that we have the right to deny your request; however, you may seek a review of the denial.RIGHT TO INSPECT AND COPYYou may inspect and obtain a copy of your protected health information that is contained in a “designated record set” for as long as we maintain the protected health information. A designated record set contains medical and billing records that may be used to make decisions about your healthcare. We may deny your access to protected health information in certain circumstances. You have the right to request a review of denial by another licensed healthcare professional, designated by us as a reviewing official, who did not participate in the original denial decision.This right does not include inspection and copying of the following records: psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding; and protected health information that is subject to law that prohibits access to protected health information.RIGHT TO REQUEST AMMENDMENTIf you believe that the information we have about you is incorrect or incomplete, you may request an amendment to your protected health information as long as we maintain this information. While we will accept requests for amendment, we are not required to agree to the amendment. If we deny your request, you have the right to submit to us a written statement of disagreement with our decision, and we have the right to rebut that statement.RIGHT TO AN ACCOUNT OF DISCLOSURESYou may request that we provide you with an account of the disclosures we have made of your protected health information. This right applies to disclosures made for purposes other than treatment, payment, or healthcare operations as described in this Notice of Privacy Practices. The disclosure must have been made after April 14, 2003, and no more than 6 years from the date of request. This right excludes disclosures made to you or with your authorization, to family members or friends involved in your care, or for notification purposes. The right to receive the information is subject to additional exceptions, restrictions, and limitations as described earlier in this notice.RIGHT TO REQUEST RESTRICTIONSYou have the right to request a restriction on the use and disclosure of your protected health information. For example, you can restrict disclosure of your information to a family member. We are not required to agree to your request. If we agree, we will comply with your request, unless the information is needed to provide your emergency treatment. You may revoke a previously agreed upon restriction at any time in writing.RIGHTS TO REQUEST CONFIDENTIAL COMMUNICATIONSYou may request that we communicate with you using alternative means or at alternative locations. For example, you can ask us to use an alternative address for billing purposes. We will accommodate reasonable requests when possible.RIGHT TO OBTAIN A COPY OF THIS NOTICEYou may obtain a Notice of Privacy Practices by calling our office and requesting a copy to be mailed to you, or you can ask for a copy at your next appointment.HOW WE MAY USE OR DISCLOSE YOUR PROTECTED HEALTH INFORMATIONTREATMENTWe will use and disclose your protected health information to provide, coordinate, or manage your healthcare and any related services. This includes the coordination or management of your healthcare with a third party. For example, we would disclose your protected health information, as necessary, to doctors, nurses, and technicians who provide care to you. We may disclose your protected health information to a specialist, pharmacist, or laboratory who, at the request of your physician, becomes involved in your care by providing assistance with your healthcare diagnosis or treatment. This includes, for example, pharmacists who may be provided information on other drugs you have been prescribed to identify potential interactions. In emergencies, we will use and disclose your protected health information to provide the treatment you require.PAYMENTYour protected health information will be used, as needed, to obtain payment for your healthcare services. For example, we might need to disclose your information to your health plan to obtain approval for a treatment you are going to receive.HEALTHCARE OPERATIONSWe may use or disclose, as needed, your protected health information to support the daily activities related to healthcare. These activities include, but are not limited to, quality assessment activities, investigations, licensing, and conducting or arranging for other healthcare related activities. For example, members of the medical staff may use information in your medical records to assess the case and outcomes in your case and others like it.WE MAY USE AND DISCLOSE YOUR PROTECTED HEALTH INFORMATION FOR THE FOLLOWING PURPOSES:We may share your protected health information with our business associates, such as our billing company. We require business associates to appropriately safeguard your protected health information. We may contact you to provide appointment reminders, as well as to discuss possible treatment alternatives, health related benefits, or services. For example, your name and address may be used to send you a newsletter about the services we offer. We may also send you information about products or services that we believe might benefit you. We may disclose information about you to your family members or friends, as well as anyone who is involved in your medical care or who helps pay for your care. We may disclose your information to an entity assisting in a disaster relief effort; we may also notify a family member, or another person responsible for your care, of your condition, status, and location.OTHER PERMITTED OR REQUIRED USES AND DISCLOSURESWe may use or disclose you protected health information if law or regulation requires the use or disclosure. We must disclose health information to the Secretary of the Department of Health and Human Services (DHHS) for investigations or determinations of our compliance with laws regarding the protection of your health information.PUBLIC HEALTH ACTIVITIESWe may disclose your protected health information to a public health authority that is permitted by law to collect or receive the information. The disclosure may be necessary to do the following: prevent or control disease, injury, or disability; report births and deaths; report child abuse or neglect; report reactions to medications or problems with products; notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition; notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect, or domestic violence.COMMUNICABLE DISEASESWe may disclose your protected health information, if authorized by law, to a person who might have been exposed to a communicable disease or might otherwise be at risk of contracting or spreading the disease or condition.HEALTH OVERSIGHT ACTIVITIESWe may disclose protected health information to a health oversight agency for activities authorized by law, such as: audits, investigations, and inspections. These health oversight agencies might include government agencies that oversee the health care system, government benefit programs, other government regulatory programs, and civil rights laws.FOOD AND DRUG ADMINISTRATIONWe may disclose protected health information to a person or company required by the Food and Drug administration to do the following: report adverse events, product defects, or problems and biologic product deviations; track products; enable product recalls; make repairs or replacements; conduct post-marketing surveillance as required.LEGAL PROCEEDINGWe may disclose protected health information during any judicial or administrative proceeding, in response to a court order or administrative order (if such a disclosure is expressly authorized), and in certain conditions in response to a subpoena, discovery request, or other lawful process.LAW ENFORCEMENTWe may disclose protected health information for law enforcement purposes, including the following: responses to legal proceedings, information requests for identification and location, circumstances pertaining to victims of a crime, deaths suspected form criminal conduct, crimes occurring at our premises, medical emergencies (not on our premises) believed to result from criminal conduct.CORONERS, FUNERAL DIRECTORS, AND ORGAN DONATIONSWe may disclose protected health information to coroners or medical examiners for identification to determine the cause of death or for the performance of other duties authorized by law. We may also disclose protected health information to funeral directors as authorized by law. If you are an organ donor, we may release your protected health information to the appropriate organizations or to an organ donation bank.RESEARCHWe may disclose your protected health information to researchers when authorized by law, for example, if their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your protected health information.TO AVERT SERIOUS THREAT TO HEALTH OR SAFETYUnder applicable federal and state laws, we may disclose your protected health information if we believe that its use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public.MILITARY ACTIVITY AND NATIONAL SECURITYWe may disclose your protected health information as required by military command authorities, for national security purposes or to protective services for the President.WORKERS’ COMPENSATIONWe may disclose your protected health information to comply with workers’ compensation laws and other similar legally established programs that provide benefits for work related injuries or illness.INMATESWe may use or disclose your protected health information if you are an inmate of a correctional facility or under the custody of a law enforcement official. This disclosure would be necessary (1) for the institution to provide you with health care, (2) for your health and safety or the health and safety or others, or (3) for the safety and security of the correctional institution.USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION REQUIRING YOUR PERMISSIONWe will not use or disclose your protected health information for any other purpose without your written authorization, unless otherwise permitted or required by law. Once given, you may revoke your authorization in writing at any time, except to the extent that we have already taken action on the information disclosed.OUR DUTIES TO YOU REGARDING PROTECTED HEALTH INFORMATIONWe are required by law to do the following:Make sure that your protected health information is kept privateGive you this notice of our legal duties and privacy practices related to the use and disclosure of your protected health informationAbide by the terms of the notice currently in effectCommunicate any changes in the notice to you We reserve the right to change this notice and to make the revised or changed notice effective for health information we already have about you as well as any information we receive in the future. The current notice will be posted in our office. You may obtain a notice of privacy practices by calling our office and requesting a copy be mailed to you or you can ask for a copy at your next appointment.COMPLAINTSIf you believe your privacy rights have been violated, you may file a written complaint with our Privacy Officer or with the Secretary of the Department of Health and Human Services. We will not retaliate against you or penalize you for filing a complaint.CONTACT INFORMATIONIf you have any questions, requests, or complaints, please contact our Privacy Officer at (212) 693-4010. Date:* Date Format: MM slash DD slash YYYY Patient Name PHARMACY INFORMATIONName:*Address*City*State*New YorkAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingZip*Phone:*NameThis field is for validation purposes and should be left unchanged.