Jennifer Perera, LCSW – NJ License # 44SC05720200

Interval Health LLC

476 South Avenue East, Cranford, NJ 07016

20 Nassau Street, Suite 111, Princeton, NJ 08540

www.intervalhealth.com

NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW THIS NOTICE CAREFULLY.

Your health record contains personal information about you and your health. This information about you that may identify you and that relates to your past, present or future physical or mental health condition and related health care services is referred to as Protected Health Information (“PHI”). This Notice of Privacy Practices describes how we may use and disclose your PHI in accordance with applicable law, including the Health Insurance Portability and Accountability Act (“HIPAA”), regulations promulgated under HIPAA including the HIPAA Privacy and Security Rules, and the NASW Code of Ethics. It also describes your rights regarding how you may gain access to and control your PHI.

We are required by law to maintain the privacy of PHI and to provide you with notice of our legal duties and privacy practices with respect to PHI. We are required to abide by the terms of this Notice of Privacy Practices. We reserve the right to change the terms of our Notice of Privacy Practices at any time. Any new Notice of Privacy Practices will be effective for all PHI that we maintain at that time. We will provide you with a copy of the revised Notice of Privacy Practices by sending a copy to you in the mail upon request or providing one to you at your next appointment.

I. MY PLEDGE REGARDING HEALTH INFORMATION:

I understand that health information about you and your health care is personal. I am committed to protecting health information about you. I create a record of the care and services you receive from me. I need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by this mental health care practice. This notice will tell you about the ways in which I may use and disclose health information about you. I also describe your rights to the health information I keep about you, and describe certain obligations I have regarding the use and disclosure of your health information. I am required by law to:

  • Make sure that protected health information (“PHI”) that identifies you is kept private.

  • Give you this notice of my legal duties and privacy practices with respect to health information.

  • Follow the terms of the notice that is currently in effect.

  • I can change the terms of this Notice, and such changes will apply to all information I have about you. The new Notice will be available upon request in my office.

II. HOW I MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU:

The following categories describe different ways that I use and disclose health information. For each category of uses or disclosures I will explain what I mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways I am permitted to use and disclose information will fall within one of the categories.

For Treatment: Federal privacy rules (regulations) allow health care providers who have a 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. I 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, in order 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 in order 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.

 

For Payment: If you elect to have treatment covered by your insurance provider, we may use and disclose PHI so that we can receive payment for the treatment services provided to you. Examples of payment related activities include: making a determination of eligibility or coverage for insurance benefits, processing claims with your insurance company, reviewing services provided to you to determine medical necessity, or undertaking utilization review activities. If it becomes necessary to engage the services of a collection agency due to lack of payment for services, we will only disclose the minimum amount of PHI necessary for purposes of collection.

 

For Health Care Operations: We may use or disclose, as needed, your PHI in order to support our business activities including, but not limited to, quality assessment activities, employee review activities, licensing, and conducting or arranging for other business activities. For example, we may share your PHI with third parties that perform various business activities (e.g., billing or typing services or electronic medical records system) provided we have a written contract with the business that requires it to safeguard the privacy of your PHI.

Lawsuits and Disputes: If you are involved in a lawsuit, I may disclose health information in response to a court or administrative order. I may also disclose health information about you 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.

 

Required by Law: Under the law, we must disclose your PHI to you upon your request. In addition, we must make disclosures to the Secretary of the Department of Health and Human Services for the purpose of investigating or determining our compliance with the requirements of the Privacy Rule.

III. CERTAIN USES AND DISCLOSURES REQUIRE YOUR AUTHORIZATION:

  1. Psychotherapy Notes. I 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 my use in treating you. B. For my 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 my use in defending myself in legal proceedings instituted by you. D. For use by the Secretary of Health and Human Services to investigate my 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. As a psychotherapist, I will not use or disclose your PHI for marketing purposes.

  3. Sale of PHI. As a psychotherapist, I will not sell your PHI in the regular course of my business.

IV. CERTAIN USES AND DISCLOSURES DO NOT REQUIRE YOUR AUTHORIZATION.

Information shared during treatment is confidential except under certain circumstances. Applicable law and ethical standards permit us to disclose information about you without your authorization only in a limited number of situations. Subject to certain limitations in the law, I 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. To prevent a medical or psychiatric emergency, I may disclose your PHI to a medical professional or immediate family member or friend in order to prevent serious harm (i.e, you express your intention to harm yourself or we observe and believe that your emotional/mental state puts you at risk to do so or you express that you intend to do bodily harm to another person).

  4. To protect the safety of the public, I may disclose your PHI if necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. If information is disclosed to prevent or lessen a serious threat it will be disclosed to a person or persons reasonably able to prevent or lessen the threat, including the target of the threat.

  5. For health oversight activities, including audits and investigations.

  6. 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.

  7. For law enforcement purposes, including reporting crimes occurring on my premises.

  8. To coroners or medical examiners, when such individuals are performing duties authorized by law.

  9. 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.

  10. For deceased patients, I may disclose PHI as mandated by state law, or to a family member or friend that was involved in your care or payment for care prior to death, based on your prior consent. A release of information regarding deceased patients may be limited to an executor or administrator of a deceased person’s estate or the person identified as next-of-kin. PHI of persons that have been deceased for more than fifty (50) years is not protected under HIPAA.

  11. Specialized government functions, including, ensuring the proper execution of military missions; protecting the President of the United States; conducting intelligence or counter-intelligence operations; or, helping to ensure the safety of those working within or housed in correctional institutions.

  12. For workers’ compensation purposes. Although my preference is to obtain an Authorization from you, I may provide your PHI in order to comply with workers’ compensation laws.

  13. Appointment reminders and health related benefits or services. I may use and disclose your PHI to contact you to remind you that you have an appointment with me. I may also use and disclose your PHI to tell you about treatment alternatives, or other health care services or benefits that I offer.

V.         CERTAIN USES AND DISCLOSURES WITH AUTHORIZATION:

Psychiatrist/additional mental health services: If you are currently receiving any additional mental health services, are taking medication for a mental health condition, need psychiatric care while receiving therapy, or if you have had previous mental health services, we will request that you provide authorization so that we may speak with your prescribing physician, therapist or clinic in order to provide appropriate continuity of care.

Referrals to additional medical professionals: If you complain of physical symptoms or you develop any serious physical symptoms while receiving treatment, I will request that you obtain a physical examination to rule out any medical basis for your symptoms. In order to provide appropriate continuity of care, we will request that you provide authorization so that we may speak with this additional medical provider.

Family Involvement in Care: Routine disclosures of your PHI to close family members or friends directly involved in your treatment will only occur to facilitate your progress in treatment. These types of disclosures will only occur with your consent.

VI. 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 me not to use or disclose certain PHI for treatment, payment, or health care operations purposes. I am not required to agree to your request, and I may say “no” if I 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 I Send PHI to You. You have the right to ask me to contact you in a specific way (for example, home or office phone) or to send mail to a different address, and I 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 I have about you. Your right to inspect and copy PHI will be restricted only in those situations where there is compelling evidence that access would cause serious harm to you. I 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 I may charge a reasonable, cost based fee for doing so.

  5. The Right to Get a List of the Disclosures I Have Made. You have the right to request a list of instances in which I have disclosed your PHI for purposes other than treatment, payment, or health care operations, or for which you provided me with an Authorization. I will respond to your request for an accounting of disclosures within 60 days of receiving your request. The list I will give you will include disclosures made in the last six years unless you request a shorter time. I will provide the list to you at no charge, but if you make more than one request in the same year, I 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 I correct the existing information or add the missing information. I may say “no” to your request, but I 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.

ORIGINAL DATE OF THIS NOTICE WAS 05/25/2018.

THIS NOTICED WAS AMENDED AS OF 02/25/2019.

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 this Notice of Privacy Practices.

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476 SOUTH AVENUE EAST
CRANFORD, NJ 07016
20 NASSAU STREET
PRINCETON, NJ 08542
(973) 337-0586
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© 2019 Interval Health LLC

If you are experiencing suicidal thoughts, call the National Suicide Prevention Lifeline at 1-800-273-8255, a free 24-hour hotline available to anyone in suicidal crisis or emotional distress. You will be routed to the nearest city crisis center to you. 
 

 

Serving Westfield, West Orange, Princeton, Lawrenceville, Hamilton, Summit, Livingston, Millburn, Maplewood, South Orange, Warren, Scotch Plains, Mountainside, Cranford, Garwood, New Providence, Berkeley Heights, Montclair, Glen RIdge, Verona and surrounding areas.