Dr. Patricia DeJesus DSW, LCSW-R
Clinical Social Work/Therapist
480 North Street, Middletown, NY 10940
Notice of Privacy Practices
This notice of Privacy Practices describes how I may disclose your Protected Health Information (PHI) to carry out treatment, help you file for insurance payment and for other purposes that may be required by law. It also describes your rights to access and control your PHI (i.e., any information that may identify you and that relates to your past, present or future physical or mental health and/or related health care services which I may have on file or have direct knowledge of.) I will ask you to sign a consent form allowing me to use this information should the need arise.
I am required by law (i.e., the 2003 Federal Health Insurance Portability and Accountability Act and later revisions) to maintain the privacy of your PHI and to follow the terms of this notice. The terms of the notice may be revised as needed to reflect future changes in the law, which will then apply to all PHI that I maintain at that time. I will provide you a copy of any revised notices by posting a copy on my website (www.secondchancecounselingny.com) or if you request, by mailing or giving you one directly to you.
How I may disclose health information about you.
Treatment: As you know, I need to collect some of your PHI in order to provide you with effective psychotherapy. With your consent, I may disclose your PHI for the purpose of coordinating or managing your health care treatment with a physician or other healthcare provider should this become necessary and be beneficial to you.
Insurance Payment: I may need to disclose some of your basic PHI so that you may receive reimbursement for payments you make to me for my services (assuming I am an out -of-network provider and you choose to file a claim). Examples of payment-related activities may include reviewing with your insurance company the services provided to you to help them determine medical necessity or undertaking utilization review activities when your insurance company requires it.
Required by Law: Under the law I must make limited disclosures to the Secretary of the Department of Health and Human Services for the purpose of investigating or determining my compliance with the Privacy Rule should they demand I do so.
Use and Disclosures of PHI Not Requiring Consent or Authorization: There are a limited number of situations in which the law and the ethical standards of my profession compel me to disclose information about you without your consent or authorization. These include:
1) Suspected child or elder abuse or neglect must be reported.
2) A serious threat of physical violence against oneself (self-harm) or a reasonably identifiable victim or victims (harm to other(s)) must be reported to law enforcement and/or the threatened person(s).
3) A court order (which would follow my attempting to contact you about the request and you waiving your right to challenge the release of any information to the court. Depending upon the situation, such challenges may be successful, and no information is released. Other times, some information is ordered to be released. In which case, I must comply with this court order and release the information.)
4) Mandatory government agency audits or investigations, such as the New York Licensing Board for counselors that issues and maintains my license may require release of certain information.
Your rights regarding your protected health information.
You have the following rights regarding the PHI I maintain about you. To exercise any of these rights please submit your request to me in writing as I will need to document this request.
You have the right to inspect, review and to copy the PHI I have on file. Your right to inspect and copy PHI will be restricted only in those situations where there is compelling evidence that access would cause harm to you. I may charge a reasonable, cost-based fee for providing these copies.
You have the right to amend the records I maintain. If you believe that the PHI I have about you is incorrect or incomplete, you may ask me to amend the information. In certain cases, I may deny your request.
You have the right to request a restriction of your protected health information. You may ask me not to use or disclose any part of your PHI for treatment, payment, or health care operations. Your request must state the specific restriction requested and to whom you want the restriction to apply. By law, I am not required to agree to your request (e.g., cases of child or elder abuse as discussed above).
You have the right to an accounting of disclosures of your PHI that I make. No accounting is made for release of PHI disclosed by authorization. I may charge a reasonable fee if you request more than one accounting in any12 month period.
You have the right to file a complaint if you believe that I have violated your privacy rights. You can file a complaint with the Secretary of the Department of Health and Human Services at www.hhs.gov. All complaints must be in writing. Filing a complaint will not change the treatment I provide you in any way.
If you have any questions regarding this notice or have questions about my health information privacy policies, please contact me (see contact information above).
For more information about HIPPA, go to: