THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE READ IT CAREFULLY.
NOTICE OF PRIVACY PRACTICES

The following is the Notice of Privacy Practices of Dr. Samantha Dreyer, Psychologist. HIPAA is a federal law that requires us to maintain the privacy of your protected health information and to provide you with notice of our legal duties and privacy policies with respect to your protected health information. We are required by law to abide by the terms of this Notice of Privacy Practices.

Your Protected Health Information

Your "protected health information" (PHI) broadly includes any health information, oral, written or recorded, that is created or received by us, other healthcare providers, and health insurance companies or plans, that contains data, such as your name, address, social security or patient identification number, and other information, that could be used to identify you as the individual patient who is associated with that health information.

Rules on How We May Use or Disclosure Your Protected Health Information

Generally, we may not "use" or "disclose" your PHI without your permission, and must use or disclose your PHI in accordance with the terms of your permission. "Use" refers generally to activities within our office. "Disclosure" refers generally to activities involving parties outside of our office. The following are the circumstances under which we are permitted or required to use or disclose your PHI. In all cases, we are required to limit such uses or disclosures to the minimal amount of PHI that is reasonably required.

Without Your Written Authorization, Treatment, Payment and Health Operations

Without your written authorization, we may use within our office, or disclose to those outside our office, your PHI in order to provide you with the treatment you require or request, to collect payment for our services, and to conduct other related health care operations as follows:

Treatment activities include: (a) use within our office by our professional staff for the provision, coordination, or management of your health care at our office; and (b) our contacting you to provide appointment reminders or information about treatment alternatives or other health-related services that may be of interest to you.

Payment activities include: (a) if you initially consent to treatment using the benefits of your contract with your health insurance plan, we will disclose to your health plans or plan administrators, or their appointed agents, PHI for such plans or administrators to determine coverage, for their medical necessity reviews, for their appropriateness of care reviews, for their utilization review activities, and for adjudication of health benefit claims; (b) disclosures for billing for which we may utilize the services of outside billing companies and claims processing companies with which we have Business Associate Agreements that protect the privacy of your PHI; and (c) disclosures to attorneys, courts, collection agencies and consumer reporting agencies, of information as necessary for the collection of our unpaid fees, provided that we notify you in writing prior to our making collection efforts that require disclosure of your PHI.

Health care operations include: (a) use within our office for training of our professional staff and for internal quality control and auditing functions (b) use within our office for general administrative activities such as filing, typing, etc.; and (c) disclosures to our attorney, accountant, bookkeeper and similar consultants to our healthcare operations, provided that we shall have entered into Business Associate Agreements with such consultants for the protection of your PHI.

PLEASE NOTE THAT UNLESS YOU REQUEST OTHERWISE, AND WE AGREE TO YOUR REQUEST, WE WILL USE OR DISCLOSE YOUR PERSONAL HEALTH INFORMATION FOR TREATMENT ACTIVITIES, PAYMENT ACTIVITIES, AND HEALTHCARE OPERATIONS AS SPECIFIED ABOVE, WITHOUT WRITTEN AUTHORIZATION FROM YOU.

Without Your Written Authorization, Special Situations and As Required By Law

In limited circumstances, we may use or disclose your PHI without your written authorization and in accord with HIPAA or as required by law. Examples include: (a) disclosures regarding reports of child abuse or neglect, including reporting to social service or child protective services agencies; (b) disclosures to State authorities of imminent risk of danger presented by patients to self or others for the purpose of restricting patient access to firearms; (c) health oversight activities including audits, civil, administrative, or criminal investigations, inspections, licensure or disciplinary actions, or civil, administrative, or criminal proceedings or actions, or other activities necessary for appropriate oversight of government benefit programs; (d) judicial and administrative proceedings in response to an order of a court or administrative tribunal, or other lawful process; (e) to the extent necessary to protect you or others from a serious imminent risk of danger presented by you; (f) for worker's compensation claims, (g) as required by the Secretary of Health and Human Services to investigate or determine our compliance with federal regulations, including those regarding government programs providing public benefits, (h) for research projects where your PHI has been de-identified, that is no longer identifies you by name or any distinguishing marks, and cannot be associated with you, (i) to a public or private entity to assist in disaster relief efforts authorized by law, (j) to family members, friends and others involved in your care, but only if you are present and give oral permission

Minimum Necessary Rule: We will use or disclose your PHI without your authorization for the above purposes only to the extent necessary, and will release only the minimum necessary amount of PHI to accomplish the purpose.

All Other Situations, With Your Specific Written Authorization

Except as otherwise permitted or required as described above, we may not use or disclose your PHI without your written authorization. Written authorization is required, among other uses and disclosures, for (1) most uses and disclosures of Psychotherapy Notes, (2) uses and disclosures for marketing purposes, (3) uses and disclosures that involve the sale of PHI and (4) other uses and disclosures not described in this Notice. Further, we are required to use or disclose your PHI consistent with the terms of your authorization. You may revoke your authorization to use or disclose any PHI at any time, except to the extent that we have taken action in reliance on such authorization, or, if you provided the authorization as a condition of obtaining insurance coverage, other law provides the insurer with the right to contest a claim under the policy. We will not sell your PHI or use your PHI for paid marketing or fundraising purposes without your written authorization; we do not plan to use your PHI in marketing or fundraising.

Special Handling of Psychotherapy Notes

"Psychotherapy Notes" are defined as records of communications during individual or family counseling which may be maintained in addition to and separate from medical or healthcare records. Psychotherapy Notes are only released with your specific written authorization except in limited instances, including: (a) if you sue us or place a complaint, we may use Psychotherapy Notes in our defense; (b) to the United States Department of Health and Human Services in an investigation of our compliance with HIPAA; (c) to health oversight agencies for a lawful purpose related to oversight of our practice; and (d) to the extent necessary to protect you or others from a serious imminent risk of danger presented by you. Health insurers may not condition treatment, payment, enrollment, or eligibility for benefits on obtaining authorization to review, or on reviewing, Psychotherapy Notes.

Your Rights With Respect to Your Protected Health Information

Under HIPAA, you have certain rights with respect to your PHI. The following is an overview of your rights and our duties with respect to enforcing those rights.

Right To Request Restrictions On Use Or Disclosure

You have the right to request restrictions on certain uses and disclosures of your PHI. While we are not required to agree to any requested restriction, if we agree to a restriction, we are bound not to use or disclose your protected healthcare information in violation of such restriction, except in certain emergency situations. We will not accept a request to restrict uses or disclosures that are otherwise required by law. If you have paid for our services in full yourself, out-of-pocket, then we must comply with your request to restrict those disclosures of your PHI that would otherwise be made for payment or healthcare operations, that are unnecessary because of your manner of payment. We require that all requests for restrictions be in writing and specify (1) the information to be restricted, (2) the type of restriction being requested, and (3) to whom the limits apply. You must also state a reason for the request. We will respond in writing to all requests within 30 days or receipt.

Right To Receive Confidential Communications By Alternative Means And At Alternative Locations

We must permit you to request and must accommodate reasonable requests by you to receive communications of PHI from us by alternative means or at alternative locations. We will ask you how you wish us to communicate with you. We must agree to your request if you inform us that certain of means of communicating with you will place you in danger.

Right To Inspect and Copy Your Protected Health Information, Including In Electronic Format

You have the right of access in order to inspect, and to obtain a copy of your PHI, including any PHI maintained in electronic format, except for (a) personal notes and observations of the treating provider, (b) information compiled in reasonable anticipation of, or for use in, a civil, criminal, or administrative action or proceeding, (c) health information maintained by us to the extent to which the provision of access to you is at our discretion, and we exercise our professional judgment to deny you access, and (d) health information maintained by us to the extent to which the provision of access to you would be prohibited by law.

We require written requests for copies of your PHI; they should be sent to our Privacy-Security Officer at the mailing address below. You may request your PHI in the format of your choice, and where feasible, we will comply. If you request a copy of your PHI, we will charge a fee for copying, or for electronic records, for labor and supplies. We reserve the right to deny you access to and copies of all or certain PHI as permitted or required by law. Upon denial of a request for access or request for information, we will provide you with a written denial specifying the basis for denial, a statement of your rights, and a description of how you may file an appeal or complaint.

Right To Amend Your Protected Health Information

You have the right to request that we amend your PHI, for as long as your medical record is maintained by us. We have the right to deny your request for amendment. We require that you submit written requests and provide a reason to support the requested amendment.

If we deny your request, we will provide you with a written denial stating the basis of the denial, your right to submit a written statement disagreeing with the denial, and a description of how you may file a complaint with us and/or the Secretary of the U.S. Department of Health and Human Services (DHHS). If we accept your request for amendment, we will make reasonable efforts to provide the amendment within a reasonable time to persons identified by you as having received PHI of yours prior to amendment and persons that we know have the PHI that is the subject of the amendment and that may have relied, or could foreseeably rely, on such information to your detriment. All requests for amendments shall be sent to our Privacy-Security Officer at the mailing address below.

Right To Receive An Accounting Of Disclosures Of Your PHI And Electronic Health Records

You have the right to receive a written accounting of all disclosures of your PHI for which you have not provided an authorization that we have made within the six (6) year period immediately preceding the date on which the accounting is requested. You may request an accounting of such disclosure for a period of time less than six (6) years from the date of the request. We require that you request an accounting in writing on a form that we will provide to you.

The accounting of disclosures will include the date of each disclosure, the name and, if known, the address of the entity or person who received the information, a brief description of the information disclosed, and a brief statement of the purpose and basis of the disclosure or, instead of such statement, a copy of your written authorization or written request for disclosure pertaining to such information. We are not required to provide accountings of disclosures for the following purposes: (a) treatment, payment, and healthcare operations, (b) disclosures pursuant to your authorization, (c) disclosures to you, (d) to other healthcare providers involved in your care, (e) for national security or intelligence purposes, (f) to correctional institutions, and (g) with respect to disclosures occurring prior to 4/14/2003. We reserve the right to temporarily suspend your right to receive an accounting of disclosures to health oversight agencies or law enforcement officials, as required by law. We will provide the first accounting to you in any twelve (12) month period without charge, but will impose a reasonable cost-based fee for responding to each subsequent request for accounting within that same twelve (12) month period. All requests for an accounting shall be sent to our Privacy-Security Officer at the mailing address below.

If we maintain any PHI in electronic form, then you may also request and receive an accounting of any disclosures of your electronic health records made for purposes of treatment, payment and health operations during the prior three (3) year period. Upon request, one list will be provided for free every twelve (12) months.

Right To Notification If There Is A Breach of Your Protected Health Information

If there is a breach in our protecting your PHI, we will follow HIPAA guidelines to evaluate the circumstances of the breach, document our investigation, retain copies of the evaluation, and where necessary, report breaches to DHHS. Where a report is required to DHHS, we will also give you notification of any breach.

Business Associate Rule

Business Associates are entities that in the course of our business with them will obtain access to your PHI. They may use, transmit, or view your PHI on our behalf. Business Associates are prohibited from re-disclosing your PHI without your written consent, or unless disclosure is required by law. We enter into confidentiality agreements with our Business Associates called Business Associate Agreements, and they in turn enter into confidentiality agreements with their subcontractors, if any.

Complaints

You may file a complaint with us and with the Secretary of DHHS if you believe that your privacy rights have been violated. Please submit any complaint to us in writing by mail to our Privacy-Security Officer at the mailing address below. A complaint must name the subject of the complaint and describe the acts or omissions believed to be in violation of the applicable requirements of HIPAA or this Notice of Privacy Practices. A complaint must be received by us or filed with the Secretary of DHHS within 180 days of when you knew or should have known that the act or omission complained of occurred. You will not be retaliated against for filing any complaint. To file a complaint with the Secretary of DHHS, write or call:

The US Department of Health & Human Services
Office of Civil Rights
200 Independence Avenue, SW
Washington, DC 20201
877-696-6775

Amendments to this Notice of Privacy Practices

We reserve the right to revise or amend this Notice of Privacy Practices at any time. These revisions or amendments may be made effective for all PHI we maintain even if created or received prior to the effective date of the revision or amendment. Upon your written request, we will provide you with notice of any revisions or amendments to this Notice of Privacy Practices, or changes in the law affecting this Notice of Privacy Practices, by mail or electronically within 60 days of receipt or your request.

Ongoing Access to Notice of Privacy Practices

We will provide you with a copy of the most recent version of this Notice of Privacy Practices at any time upon your written request sent to our Privacy-Security Officer at the mailing address below. For any other requests or for further information regarding the privacy of your PHI, and for information regarding the filing of a complaint, please contact us at the address, telephone number, or e-mail address listed below.

To Contact Us

This is our contact information referred to above.
Our Privacy-Security Officer is: A. Samantha Dreyer, Psy.D. Our mailing address is: 1050 Hallock Ave, Suite 2, Port Jefferson Station, NY 11776. Our telephone number is: (631) 880-1178. Our fax number is: (631) 928-3420. Our email address is: drsamanthadreyer@yahoo.com.

This form documents that I give my consent to A. Samantha Dreyer, Psy.D. (the "psychologist") to provide psychotherapeutic treatment to me.

            While I expect benefits from this treatment, I fully understand that no particular outcome can be guaranteed.  I understand that I am free to discontinue treatment at any time but that it would be best to discuss with the psychologist any plans to end therapy before doing so.

            I have fully discussed with the psychologist what is involved in psychotherapy and I understand and agree to the policies about scheduling, fees and missed appointments.  I understand that I am fully financially responsible for treatment, which, if I have health insurance, includes any portion of the psychologist's fees that are not reimbursed by my insurance.   I understand that the frequency of my sessions will vary according to my needs but will typically occur on a weekly basis, that I am fully responsible for payment of all deductibles and co-payments if I have health insurance, that I will be billed for each session, and that payment will be due at the session that immediately follows my receipt of a bill, and that I will be personally responsible for the missed session fee for any canceled session if I do not give the psychologist at least 24 hours advance notice of the cancellation (please note that insurers don't pay for canceled sessions)

            Our discussion about therapy has included the psychologist's evaluation and diagnostic formulation of my problems, the method of treatment, goals and length of treatment, and information about record-keeping.  I have been informed about and understand the extent of treatment, its foreseeable benefits and risks, and possible alternative methods of treatment.  I understand that therapy can sometimes cause upsetting feelings to emerge, that I may feel worse temporarily before feeling better, and that I may experience distress caused by changes I may decide to make in my life as a result of therapy.

            I understand that the psychologist cannot provide emergency services.  The psychologist has told me whom to call if an emergency arises and the psychologist is unavailable.  In any case, I understand that in any emergency, I may call 911 or go the nearest hospital emergency room.

            I have received a HIPAA Notice of Privacy Practices from the psychologist.  I understand that information about psychotherapy is almost always kept confidential by the psychologist and not revealed to others unless I give my consent.  There are a few exceptions as noted in the HIPAA Notice of Privacy Practices.  Details about certain of those exceptions follow:

            1.  The psychologist is required by law to report suspected child abuse or neglect to the proper authorities. The psychologist is also mandated to report to the authorities patients who are at imminent risk of harming themselves or others for the purpose of those authorities checking to see whether such patients are owners of firearms, and if they are, or apply to be, then limiting and possibly removing their ability to possess them.

            2.  If I tell the psychologist that I intend to harm another person, the psychologist must try to protect that person, including by telling the police or the person or other health care providers.  Similarly, if I threaten to harm myself, or my life or health is in any immediate danger, the psychologist will try to protect me, including by telling others such as my relatives or the police or other health care providers, who can assist in protecting or assisting me.

            3.  If I am involved in certain court proceedings the psychologist may be required by law to reveal information about my treatment.  These situations include child custody disputes, cases where a therapy patient's psychological condition is an issue, lawsuits or formal complaints against the psychologist, civil commitment hearings, and court-related treatment.

            4.  If my health insurance or managed care plan will be reimbursing me or paying the psychologist directly, they will require that I waive confidentiality and that the psychologist give them information about my treatment.

            5.  The psychologist may consult with other psychologists about my treatment, but in doing so will not reveal my name or other information that would identify me unless specific consent to do so is obtained.  Further, when the psychologist is away or unavailable, another psychologist might answer calls and so will need to have access to information about my treatment.

            6.  If my account with the psychologist becomes overdue and I do not pay the amount due or work out a payment plan, the psychologist will reveal a limited amount of information about my treatment in taking legal measures to be paid.  This information will include my name, patient identification number, address, dates and type of treatment and the amount due.

In all of the situations described above I understand that the psychologist will try to discuss the situation with me, or notify me, before any confidential information is revealed, and will reveal only the least amount of information that is necessary.

            If I am participating in a managed care plan, I have discussed with the psychologist the plan's limits, if any, on the number of therapy sessions.  I have discussed with the psychologist my options for continuation of treatment when my managed care benefits end.

            I understand that I have a right to ask the psychologist about the psychologist's training and qualifications and about where to file complaints about the psychologist's professional conduct.

            My electronic signature indicates that I have read and understood this form and that I give my consent to treatment.

Definition of Services:

30-minute individual psychotherapy session - $140

Initial diagnostic evaluation (90-minutes to 2-hours face-to-face plus time to create case formulation) - $550

Missed appointment (without 24 hours' notice; insurers do not pay for missed or canceled sessions) - $150

Hourly fee for any other service provided by Dr. Samantha Dreyer, including but not limited to consultation with other providers at patient's request, involvement in court proceedings of any kind, or writing evaluation reports - $240

Dr. Samantha Dreyer reserves the right to change these fees, and rates will be changed at least once per year, usually on January 1st. Changed rates will be effective for treatment conducted after the rate change is effective. Notification of rate changes will be given one month prior to any rate change.

            My electronic signature indicates full understanding and agreement to these fees and terms of financial responsibility.

I assign my rights to payment to my health services provider, Alice Samantha Dreyer, Psy.D. I want Alice Samantha Dreyer, Psy.D. to seek payment for any health services that she has provided and/or will provide to me from my insurance company. I want my health insurer to pay Alice Samantha Dreyer, Psy.D. for any health care services I receive from her that are covered under my health insurance. If my insurer pays me for the services, I agree to send the payment to Alice Samantha Dreyer, Psy.D.  If my insurer changes, this authorization will remain in effect for billing any other insurance company.

I hereby certify that I am an authorized user/card-holder of any credit card that I enter into my patient record, and I hereby authorize any credit card that I enter into my patient record to be used for payments for services rendered by Alice Samantha Dreyer, Psy.D. d/b/a Dr. Samantha Dreyer, Psychologist.  This authorization will remain in effect until the expiration date of the card or a written request to revoke the authorization is sent to her at:

Dr. Samantha Dreyer

1050 Hallock Ave

Suite 2

Port Jefferson Station, NY 11776

Please advise Dr. Dreyer immediately if your card is lost and/or stolen.