tampa criminal attorney

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Geriatric Assessment and Planning Program
Dear New Patient and /or Caregiver,
The UNTHSC Center for Geriatrics welcomes you to our practice. We are pleased that you
have chosen us for your healthcare needs. Our board-certified geriatricians, nurse practitioners,
nurses, neuropsychologists and social service coordinators are committed to improving the
physical and mental function of our patients, with a focus on improving and maintaining their
quality of life.
Your Appointment is with on .
Please arrive for your appointment at to complete your registration.
If you are unable to keep your appointment, please call us in advance: 817-735-2200
The Geriatrics Clinic is located on the Floor of the Patient Care Center on the UNT Health
Science Center campus. We have included a map and parking directions.
What to expect during your appointment?
During the first appointment, the patient and his/her family will be seen by a number of staff
members. Because we make a complete assessment of each patient’s physical, psychological
and social condition, it is not unusual for a physician, a social worker, a nurse, and other
members of the clinic staff to take part in the examination. Since we are a teaching University,
we often have Students, Resident Doctors and Fellows in addition to other health care
professional students assisting in the clinic under an attending physician’s supervision.
We ask that you review and complete the enclosed New Patient Checklist and Medical Health
History form prior to your appointment. Also, in preparation for your appointment, you will be
contacted by a Social Worker who will obtain social health history information.
We look forward to seeing you soon.
Thank You,
Center for Geriatrics
GAPP Clinic (Geriatric Assessment & Planning Program)
855 Montgomery Street, Patient Care Center, 4
th Floor, Fort Worth, TX 76107
817-735-2200
Geriatric Assessment and Planning Program
New Patient Checklist
��� Complete Authorization for Release of Health Information form and mail, fax, or deliver
to your Physicians, so we can have your health information prior to your visit.
��� Complete the enclosed medical history form and bring them to the visit.
��� Bring all medications in the enclosed brown bag.
��� Bring Medical Power of Attorney & Directive to physician forms (if applicable) A copy
is needed for our records.
��� Bring proof of insurance including your Medicare card and supplemental insurance card.
��� Bring a calendar and a notepad for scheduling and note taking.
��� If you are changing your Primary Care Physician (PCP) to a UNT provider- Please
contact your insurance carrier to change PCP to the physician you are seeing.
If you are insured through a HMO, you must obtain a referral from you PCP and
authorization from your insurance company is required.
��� Expect a call from the Social Worker, who will obtain your social history prior to your
visit.
��� Be prepared for approximately a two to three hour new patient office visit.
855 Montgomery Street, Patient Care Center, 4
th Floor, Fort Worth, TX 76107
817-735-2200
Geriatric Assessment and Planning Program
Medical Health History Form
Patient Name: Today's Date: Age:
Years of Education/Highest Degree:
Who lives at home with you?
Martial Status: (Circle) Single Married Partner Divorced Widowed Number of Children:
How would you rate your general health: (Circle) Excellent Good Fair Poor
Name of Primary Care Physician:
Complete Physical: EKG: Chest X-Ray:
Brain CT/MRI scan: Flexible Sigmoidoscopy/Colonoscopy:
Hearing Exam: Eye Exam: Dental Exam:
Tuberculosis Skin Test: Reaction:(y/n) HIV Test:
Women's Health: Pelvic /Pap smear: Mammogram:
Men's Health: Prostate Exam:
Pneumonia Shot: Shingles Shot:
Tetanus Shot: Flu Shot:
PLEASE PROVIDE NAME AND SPECALITY OF ALL PHYSICIANS YOU SEE
MEDICATION ALLERGIES: List medication(s) you are allergic to and what reaction(s) you have
Please provide the date of last exam or procedure
Vaccinations
Name Specialty Phone
MEDICAL AND PREVENTATIVE HEALTH
Medication Name Reaction
Geriatric Assessment and Planning Program
Medical Health History Form
CURRENT MEDICATIONS: List all medications, including prescribed medications,
over-the counter medications, supplements, vitamins, and homeopathic/natural
Medication Name Dose/How Often Prescribing Doctor's Name Refill Needed (y/n)
Geriatric Assessment and Planning Program
Medical Health History Form
Pneumonia Diabetes Tuberculosis
Bronchitis Heart attack Hepatitis
Cancer: type Angina Thyroid problems
Stomach/intestinal ulcers Gall stones Gout
Kidney stones Seizures Strokes
Blood clots/phlebitis Cataracts Glaucoma
Hernias: type High cholesterol Pancreatitis
Irregular heart rhythm Diverticulosis Kidney failure
Migraine headaches Arthritis Mental illness
Parkinson's disease High blood pressure Asthma/emphysema
Sexually transmitted disease
Obstetric History
Number of pregnancies: Number of live births:
Please, include year and place treated
Please check the appropriate boxes below if you have ever been diagnosed or experienced any of the
following:
LIST ALL HOSPITILIZATIONS, SURGERIES AND SERIOUS ACCIDENTS
PAST MEDICAL HISOTRY
Geriatric Assessment and Planning Program
Medical Health History Form
Age if
living
Age at
death
FATHER
MOTHER
SIBLINGS
Please check the box of any of the following that you have experienced recently
GENERAL
Chills Malaise Weight gain Increased appetite
Fatigue Night sweats Weight loss Decreased appetite
Fever Other
HEAD, EYES, EARS, NOSE THORAT
Ear drainage Sore throat Wear glasses/contacts
Ear pain Visual changes Hearing loss
Eye discharge Seeing halos around light Ringing/Buzzing in ears
Eye pain Double vision Wear dentures/partials
Hearing loss Persistent hoarseness Sore gums
Nasal drainage Jaw pain Dry mouth
Sinus pressure Bloody nose Tooth aches
Sores in mouth Difficulty swallowing
REVIEW OF SYSTEMS
FAMILY HEALTH HISTORY
Relation Major Health Problems Cause of Death
Geriatric Assessment and Planning Program
Medical Health History Form
LUNGS
Persistent cough TB exposure Coughing up blood
Cough Shortness of breath
Difficulty breathing when laying down Other
CARDIOVASCULAR
Chest pain/pressure with exertion Ankle swelling Rapid heart beats
Leg cramps with walking Passing out/faintness
Irregular heart rhythm Other
GASTROINTESTINAL
Abdominal pain Constipation Loss of appetite
Difficulty swallowing/chokes Blood in stools Loose stool/Diarrhea
Nausea Vomiting blood Change in stools
Heartburn Food intolerance Black tarry stools
Bloating/gas Hemorrhoids
Other
UNINARY
Pain/burning on urination Difficulty emptying bladder
Blood in urine Difficulty starting urination
Frequent urination Dribbling after urination
Incontinence of urine Decrease in force of stream
Kidney/bladder infections Leak urine when cough/sneeze
Having to get to toilet quickly Repeated nighttime urination
Difficulty making it to bathroom before urine leaks
Geriatric Assessment and Planning Program
Medical Health History Form
GENITALIA
Penis Discharge Vaginal discharge/Itching
Penis Sores Vaginal bleeding
Testicle Mass Painful sex or sexual difficulties
Impotence Pelvic pain
Other Other
BREAST
Masses/Lumps Bleeding Pain
Nipple discharge Change in size Other
SKIN, HAIR, NAILS
Hair changes Itchy skin Dry skin Rash
Nail changes Mole changes Skin Lesion
Skin infection/wound Other
ENDOCRINE
Intolerance to heat Intolerance to cold Excessive thirst
Excessive hunger Excessive urination Other
MUSCULAROSKELETAL
Back pain Muscle weakness Easily broken bones Fall in the last 6 months
Joint pain Neck Pain Difficulty walking Fall with injury
Joint swelling Joint stiffness Muscle aches Other
Male Female
Geriatric Assessment and Planning Program
Medical Health History Form
HEMATOLOGY
Prolonged bleeding Bruising easily Blood transfusions
Transfusion reaction Other
IMMUNOLOGIC
Contact/Skin allergies Food allergies Seasonal allergies
Environmental allergies Other
Please list or comment below anything else that is of concern to you or that you feel we should know:
Please list your main concerns and goals for this geriatric evaluation:

1 Mind and Motion Centers of GA ��� 5050 Research Ct. #800, Suwanee, GA 30024 ��� 678-749-7600 ��� www.mindmotioncenters.com
Dear New Patient,
Thank you for allowing us to provide you our services!
To assure the most comprehensive and efficient service we can offer, please bring the following items
with you to your first appointment (* = required):
a) Driver’s License*
b) Insurance Card (If insurance is being used)*
c) Method of Payment (Cash, Check, Money Order, Credit [Visa, AMEX, MasterCard])*
d) Completed Forms (Pages 3 - 8)*
e) Completed History Intake Form Sent in Before the Day of Your Appointment*
Failure to do so can result in rescheduling or untimely delays.
f) Papers pertaining to: Court ordered evaluations, probation, police records & subpoenas (If
applicable)*
g) Previous Psychological Evaluations
h) Medical records pertaining to your visit.
i) Custodial papers
j) School Reports (past year)
We look forward to seeing you!
Sincerely,
M&M Staff
2 Mind and Motion Centers of GA ��� 5050 Research Ct. #800, Suwanee, GA 30024 ��� 678-749-7600 ��� www.mindmotioncenters.com
What to Expect From Us
After your initial appoint and if testing is being pursued
- Your proposal for testing will be submitted to your insurance for
approval.
o Proposals will only be sent to insurance if we are providers for your insurance
company. Insurance may take up to 14 days to respond to a preauthorization for
testing hours. Depending on your benefits and number of hours requested, your
insurance may choose only to cover a smaller part of the requested hours for
testing. The remaining hours will need to be dropped or covered out-of-pocket.
- Testing will be scheduled and completed.
o You will be given the results of your insurance authorization. Testing can take
anywhere between 1 – 2 days depending on the size of the battery and the
speed of the test taker. If your testing is to be done off medication, please make
sure to be off the medications for the amount of time specified by the doctor.
- A feedback appointment will be scheduled.
o The purpose of this appointment is to have the test results explained to the client.
A list of recommended therapies will also be provided.
- When do I receive my written copy of the report?
o A written, final copy of the report will be sent to the client between 3 – 5 weeks
after the feedback appointment. You may still pursue the recommended
therapies before receiving the written report.
o We provide both personal and school versions of the reports directly to you so
that you can pass them along to any party you need. Relying on us to pass
reports to other parties becomes difficult due to HIPPA regulations.
- Therapies can be scheduled with reception after the feedback
appointment.
- For questions regarding where you stand in the process, ask for
a front office manager at 678-749-7600.
3 Mind and Motion Centers of GA ��� 5050 Research Ct. #800, Suwanee, GA 30024 ��� 678-749-7600 ��� www.mindmotioncenters.com
Patient Information & Pay Agreement
Patient Information:
First Name: Last Name: DOB: Gender:
Address:
Primary
Phone:
Secondary
Phone:
Primary
Email:
Social
Security #:
Parent/Guardian/Attorney Information (If patient is under 18 years of age or if financially responsible party differs from patient):
First Name: Last Name: DOB: Gender:
Address:
Primary
Phone:
Secondary
Phone:
Primary
Email:
Social
Security #:
Patient’s Insurance Information:
Primary Insurance: Member #: Group #:
Secondary
Insurance (if
applicable): Member #: Group #:
Emergency Contact Information:
First Name: Last Name: Phone #:
First Name: Last Name: Phone #:
We accept cash, checks, money orders, and credit card (Visa, Amex, & MasterCard) payments. Returned checks
will receive an overdraft charge of $25.00 per check. If you miss your appointment without 24-hour notification
you may be assessed a $50.00 fee, and deposit may be required to schedule future appointments.
As a courtesy to you, we will complete and file an insurance form, if we are providers for your company. If not,
after completion of all services, we will send you a paid invoice for you to submit to your insurance provider.
Filing an insurance claim form on your behalf does not release you of the responsibility of paying your bill in full.
Although you may have a pre-authorization, this is not a guarantee of payment stated by your insurance company.
Ultimately, it is the responsibility of the member to keep track of benefit limits and exclusions and pre-existing
clauses on his or her policy for services as per insurance requirements and verify network status of rendering
services.
I hereby assign all medical benefits to which I am entitled to Mind and Motion, LLC (M&M). This
agreement shall remain in effect until revoked by me in writing. A photocopy of this assignment is to be
considered as valid as an original. I have read this and agree.
*___________________________________________ ______________________________________
Signature (responsible party for payment) Date
4 Mind and Motion Centers of GA ��� 5050 Research Ct. #800, Suwanee, GA 30024 ��� 678-749-7600 ��� www.mindmotioncenters.com
FEE SCHEDULE
Insurance Reimbursable Services:
Diagnostic History Interview $270.00
Psychological/Neuropsychological Testing (per Hour) $185.00
Psych Therapy/Consultation/qEEG Review (30 minutes) $67.50
Psych Therapy/Consultation/qEEG Review (45 minutes) $135.00
Psych Therapy/Consultation/qEEG Review (60 minutes) $185.00
Feedback Appointment $185.00
Occupational/Speech/Physical Therapy Evaluation $350.00
Occupational/Speech/Physical Therapy (30 minutes) $65.00
Occupational/Speech/Physical Therapy (60 minutes) $120.00
Cash Only Services:
IEP/504/Educational Consultation (per Hour) $120.00
Tutoring (per Hour) $47.50
Social Skills Groups (6 weeks; 1.5 hour sessions per week) $280.00
Handwriting Without Tears (per Hour) $120.00
SIPT Testing $950.00
Professional Record Review Time (per Hour) $185.00
qEEG with Written Report $550.00
qEEG without Written Report $135.00
Gas Mileage Reimbursement (per Mile) *
(*) Fee determined by current IRS reimbursement rate for travel.
The fees listed above do not represent contracted in-network reimbursement rates from insurance
companies. Some screening or registration fees may apply to cash only services.
In the event that I choose to proceed with services provided out-of-pocket, or should services fail to be
covered by my insurance plan/policy, I will be responsible for the full charged amount of the services
listed above.
_______________________________________________ ___________________
Signature of Financially Responsible Person(s) Date
5 Mind and Motion Centers of GA ��� 5050 Research Ct. #800, Suwanee, GA 30024 ��� 678-749-7600 ��� www.mindmotioncenters.com
Cancellation & No Show Policy
Dear Patient:
We strive to render excellent psychological care to you and the rest of our patients. In order to do so, we
have had to implement an appointment cancellation and no show policy. The policy enables us to better
utilize available appointments for our patients in need of psychological care. Patients who are not able to
keep their appointments are required to provide timely notice of cancellation prior to their appointment
time. Providing the required notice gives us the opportunity to schedule patients who may need to be
seen urgently or from a wait list so they may be seen sooner.
Due to the nature of our practice, 24-hour notice is required to change your
Appointments. Please call (678) 749-7600 to do so.
Patients who DO NOT provide the required notification for cancellation are subject to a $50.00 fee
that is NOT COVERED by insurance.
Patients who fail to pay the above fee will not be allowed to schedule future appointments until the fee is
paid.
Multiple Cancellations or No Shows will result in dismissal from our practice.
Thank you for cooperation.
*I have read and understand the rules and regulations of this policy and the penalties incurred for failing
to abide by it.
Signature:___________________________________________ Date:____________________________
*In the event that I fail to provide adequate notice of a cancellation, I assume full responsibility for the
cancellation / no show fee and allow the following credit card to be charged to render payment for this
fee.
Signature:___________________________________________ Date:____________________________
Patient Credit Card Information:
First Name:________________________________ Last Name:_________________________________
Billing Address:_______________________________________________________________________
Billing City:_______________________________ State:___________________ ZIP:________________
Credit Card Type:
Mastercard Visa Discover American Express
Credit Card #:____________________________________________ Exp Date:____________________
6 Mind and Motion Centers of GA ��� 5050 Research Ct. #800, Suwanee, GA 30024 ��� 678-749-7600 ��� www.mindmotioncenters.com
Authorization/Responsibility Agreement
Although MIND AND MOTION, LLC (M&M), as such may accept assignment of benefits, I am ultimately responsible for all
charges should my insurance company not reimburse for claims submitted.
Professional Fees and responsibility for M&M:
A. The initial intake interview is a separate fee. The report feedback session is a separate fee.
B. All fees thusly, include, a comprehensive evaluation, (where applicable) the preparation of necessary reports (where
applicable), consultation with primary care physicians (where applicable) referral to appropriate agencies and/or additional
professionals, and a conference (where applicable).
C. An additional fee is required for school consultations, plus mileage (round trip) at the predetermined IRS reimbursement rate
for travel.
D. Please note: Our office seeks reimbursement for certain costs incurred, such as computer search, telephone calls exceeding
conference allowed time, copying additional copies of reports, if lost or misplaced, or other services exceeding stated
proposals.
Insurance Coverage Responsibility/Terms:
I understand that whether I am an “out” or an “in-patient”, professional services may or may not be covered by my medical
insurance policy. And although M&M agrees to assist in completing my insurance form, it is a convenience and a courtesy to
me. However, my insurance coverage will pay according to the company terms for the services so long as I have met my
deducible for the year; but, I agree that I am ultimately responsible for the payment of the established fees regardless of
insurance coverage, in full, prior to testing or at the time of testing unless other arrangements have been made with a
representative of the billing office of M&M. If any tests are not conducted or we are unable to complete any test, the client will
be refunded toward that test with the exception of a $40.00 non-refundable fee, for electro-physiological procedures which
may include but is not limited to QEEG, EEG and rEEG.
I understand that I am responsible for monitoring the continuity of coverage and will not hold M&M responsible for inaccurate
information provided by my insurance company, or for decisions or changes made by my insurance company.
I have read the terms of this contract, have had an opportunity to ask questions about the terms of the contract, and I am of
the opinion that I fully understand the terms of this contract.
Delinquent Accounts and Collections:
I understand that a delinquent account (all claims 60 days in arrears after billing which is completed following testing) is any
account, which is not being complied with in accordance with this written agreement. I understand that the failure to pay the
fees for services may result in collection purposes (after 60 days) and should my account be turned over for collection, fees for
these services will be included. If we refer collection of your account to a lawyer, who is not our employee, you will be liable for
any reasonable attorney fees we incur to the extent permitted by law.
_________________________________________
Signature (Person or persons responsible for charges)
I authorize the release of any medical or other information necessary to process this claim for myself or concerning my minor
child where applicable, and while it is expected that those to whom such information is released will hold it confidential, I agree
to hold MIND & MOTION (M&M) harmless from violations of confidentiality arising from the release of such information by
sources other than M&M where such release has not been approved by same.
____________________________________
Signature Client/Parent/Legal Guardian/Person(s) responsible for release of information
7 Mind and Motion Centers of GA ��� 5050 Research Ct. #800, Suwanee, GA 30024 ��� 678-749-7600 ��� www.mindmotioncenters.com
CONSENT FOR RELEASE OF CONFIDENTIAL INFORMATION
Please note! No information will be sent to any party except to the client and/or parent or legal guardian as indicated without
the explicit permission.
Patient Name: _______________________________________________ Date of Birth: _________________________
M&M is networked with various professionals who provide supplemental services. By checking the boxes below, you are giving
permission for staff members of Mind and Motion, LLC (M&M) and associate (Alison Ader, ND), to review information in order
to expedite time in joint assessment practices and improve therapeutic efficiency.
I hereby authorize Mind and Motion, LLC
To release information to To obtain information from To communicate with
Alison Ader, ND
I recognize there are additional organizations, doctors, schools, etc. that would benefit from having specific information
provided to/from M&M. Therefore, I hereby authorize Mind and Motion, LLC to send/receive information to the following
parties:
Name___________________________________________________ Phone:_________________________________________
Email: ___________________________________________________ Fax: _________________________________________
Street:___________________________________________________ City:__________________ State:____ Zip:___________
Please send the following information (check appropriate box):
Psychological Report Progress Report Treatment Summary
Name___________________________________________________ Phone:_________________________________________
Email: ___________________________________________________ Fax: _________________________________________
Street:___________________________________________________ City:__________________ State:____ Zip:___________
Please send the following information (check appropriate box):
Psychological Report Progress Report Treatment Summary
Name___________________________________________________ Phone:_________________________________________
Email: ___________________________________________________ Fax: _________________________________________
Street:___________________________________________________ City:__________________ State:____ Zip:___________
Please send the following information (check appropriate box):
Psychological Report Progress Report Treatment Summary
After giving due consideration to the extent of this release, I authorize Mind and Motion, LLC to furnish information, including
photo static copies of my psychological records concerning my evaluation or treatment, to the above individual(s),
organization(s) or to its agent(s), and I further agree to indemnify and hold harmless Mind and Motion, LLC from all liability that
may arise from the release of the information herein requested. Any information released in response to this authorization
should not be re-released to any other person(s) unless I so specifically authorize. I understand that the records released may
contain alcohol and drug treatment information, medical information or psychiatric and psychological information.
I understand that information used or disclosed pursuant to the authorization may be subject to re-disclosure by the recipient
of your information and no longer protected by the HIPPA Privacy Rule.
I understand that I may revoke this consent in writing at any time, except to the extent that action has been taken in reliance
on it.
___________________________________________ ____________________________________
Patient/Client Name (Print) Date
___________________________________________ ____________________________________
Signature (Guardian Signature if Patient is under 18) Date
8 Mind and Motion Centers of GA ��� 5050 Research Ct. #800, Suwanee, GA 30024 ��� 678-749-7600 ��� www.mindmotioncenters.com
PATIENT CONFIDENTIALITY RIGHTS
We at M&M care about protecting your privacy. Evaluation findings and/or information attained through the therapy/consult
session is kept strictly confidential and may not be divulged to any other parties with the exception of the following:
The law (Health Insurance Portability & Accountability Act of 1996; HIPPA) requires the following limits of confidentiality in the
psychologist-patient relationship under the following circumstances (under these provisions, information may be provided to
third parties).
I understand that, under the HIPPA I have certain rights to privacy regarding my healthcare information. I understand that this
information can and will be used to conduct, plan and direct my treatment and follow-up among the multiple healthcare
providers who may be involved in that treatment directly and indirectly for the purpose of:
a) Suspicion of child abuse or neglect of a minor or elderly person requires mandated reporting to the appropriate
protective agencies.
b) Threats of suicide (risk to self)
c) Threats of Homicidal intentions (risks to others)
d) Court order (privilege held by patient)
e) Consented release of information
I have discussed the above limitations with my evaluator/therapist and understand the limits of confidentiality;
Patient’s Name (please print): _______________________________________________________
___________________________________________ ____________________________________
Signature (Guardian Signature if Patient is under 18) Date
CONSENT FOR AUDIO/VISUAL SURVEILLANCE
M&M may monitor testing or therapy behaviors by supervisory staff from time to time by the use of cameras and audio sensory
in their rooms. There is no recording of these behaviors unless specific permission for such is requested in writing from our
patients or their guardians. The purpose of this monitoring is to our senior staff to unobtrusively monitor behaviors in order to
assess the quality of our test data or provision of certain therapeutic services. This notice is to provide you of our intent and
obtain you permission to use this method of quality assurance in our practice.
Signing this consent form demonstrates your recognition and acceptance of this technique in providing services to you or your
family member.
Patient’s Name (please print): _______________________________________________________
___________________________________________ ____________________________________
Signature (Guardian Signature if Patient is under 18) Date
RESEARCH ACTIVITIES
Mind & Motion, LLC actively participates in research programs to facilitate the development of better diagnostic and treatment
modalities for the clients we serve. In this context, we often use data collected from our ongoing assessment and treatment
programs as a way to further understand brain behavior relationships, to establish better assessment tools, and assess methods
to validate treatment efficacy. Identifiers are removed from all data used for research presentations as well as any publications
that result from these research activities. In this way we protect the confidentiality of all the clients we serve. By signing this
agreement, you are hereby acknowledging that you recognize it is our standard practice to use our clinical data for research
activities and have no objection to the use of any clinical data gathered on you or your family member for these purposes with
an understanding that such data is protected by removal of identifiers.
Patient’s Name (please print): _______________________________________________________
___________________________________________ ____________________________________
Signature (Guardian Signature if Patient is under 18) Date
9 Mind and Motion Centers of GA ��� 5050 Research Ct. #800, Suwanee, GA 30024 ��� 678-749-7600 ��� www.mindmotioncenters.com
GEORGIA NOTICE FORM
Notice of Psychologist’s Policies and Practices to Protect the Privacy of Your Health Information
THIS NOTICE DESCRIBES HOW PSYCHOLOGICAL AND MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW
IT CAREFULLY.
I. Uses and Disclosures for Treatment, Payment, and Health Care Operations
I may use or disclose your protected health information (PHI), for treatment, payment, and health care operations purposes with your consent. To help clarify these terms, here are some
definitions:
• “PHI” refers to information in your health record that could identify you.
• “Treatment, Payment and Health Care Operations”
– Treatment is when I provide, coordinate or manage your health care and other services related to your health care. An example of treatment would be when I consult with
another health care provider, such as your family physician or another psychologist.
– Payment is when I obtain reimbursement for your healthcare. Examples of payment are when I disclose your PHI to your health insurer to obtain reimbursement for your
health care or to determine eligibility or coverage.
– Health Care Operationsare activities that relate to the performance and operation of my practice. Examples of health care operations are quality assessmentand improvement
activities, business-related matters such as audits and administrative services, and case management and care coordination.
• “Use” applies only to activities within my [office, clinic, practice group, etc.] such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.
• “Disclosure” applies to activities outside of my [office, clinic, practice group, etc.], such as releasing, transferring, or providing access to information about you to other parties.
II. Uses and Disclosures Requiring Authorization
I may use or disclose PHI for purposes outside of treatment, payment, or health care operations when your appropriate authorization is obtained. An “authorization” is written permission
above and beyond the general consent that permits only specific disclosures. In those instances when I am asked for information for purposes outside of treatment, payment or health care
operations, I will obtain an authorization from you before releasing this information. I will also need to obtain an authorization before releasing your Psychotherapy Notes. “Psychotherapy
Notes” are notes I have made about our conversation during a private, group, joint, or family counseling session, which I have kept separate from the rest of your medical record. These notes
are given a greater degree of protection than PHI.
You may revoke all such authorizations (of PHI or Psychotherapy Notes) at any time, provided each revocation is in writing. You may not revoke an authorization to the extent that (1) I have
relied on that authorization; or (2) if the authorization was obtained as a condition of obtaining insurance coverage, law provides the insurer the right to contest the claim under the policy.
III. Uses and Disclosures with Neither Consent nor Authorization
I may use or disclose PHI without your consent or authorization in the following circumstances:
• Child Abuse – If I have reasonable cause to believe that a child has been abused, I must report that belief to the appropriate authority.
• Adult and Domestic Abuse – If I have reasonable cause to believe that a disabled adult or elder person has had a physical injury or injuries inflicted upon such disabled adult or elder
person, other than by accidental means, or has been neglected or exploited, I must report that belief to the appropriate authority.
• Health Oversight Activities – If I am the subject of an inquiry by the Georgia Board of Psychological Examiners, I may be required to disclose protected health information regarding you
in proceedings before the Board.
• Judicial and Administrative Proceedings – If you are involved in a court proceeding and a request is made about the professional services I provided you or the records thereof, such
information is privileged under state law, and I will not release information without your written consent or a court order. The privilege does not apply when you are being evaluated
for a third party or where the evaluation is court ordered. You will be informed in advance if this is the case.
• Serious Threat to Health or Safety – If I determine, or pursuant to the standards of my profession should determine, that you present a serious danger of violence to yourself or another, I
may disclose information in order to provide protection against such danger for you or the intended victim.
• Worker’s Compensation – I may disclose protected health information regarding you as authorized by and to the extent necessary to comply with laws relating to worker’s
compensation or other similar programs, established by law, that provide benefits for work-related injuries or illness without regard to fault.
IV. Patient’s Rights and Psychologist’s Duties
Patient’s Rights:
• Right to Request Restrictions – You have the right to request restrictions on certain uses and disclosures of protected health information. However, I am not required to agree to a
restriction you request.
• Right to Receive Confidential Communications by Alternative Means and at Alternative Locations – You have the right to request and receive confidential communications of PHI by
alternative means and at alternative locations. (For example, you may not want a family member to know that you are seeing me. On your request, I will send your bills to another
address.)
• Right to Inspect and Copy – You have the right to inspect or obtain a copy (or both) of PHI in my mental health and billing records used to make decisions about you for as long as the PHI
is maintained in the record. I may deny your access to PHI under certain circumstances, but in some cases you may have this decision reviewed. On your request, I will discuss with you
the details of the request and denial process.
• Right to Amend – You have the right to request an amendment of PHI for as long as the PHI is maintained in the record. I may deny your request. On your request, I will discuss with
you the details of the amendment process.
• Right to an Accounting – You generally have the right to receive an accounting of disclosures of PHI. On your request, I will discuss with you the details of the accounting process.
• Right to a Paper Copy – You have the right to obtain a paper copy of the notice from meupon request, even if you have agreed to receive the notice electronically.
Psychologist’s Duties:
• I am required by law to maintain the privacy of PHI and to provide you with a notice of my legal duties and privacy practiceswith respect to PHI.
• I reserve the right to change the privacy policies and practices described in this notice. Unless I notify you of such changes, however, I am required to abide by the terms currently in
effect.
• If I revise my policies and procedures, I will provide you a copy at your next appointment, post the revisions, and have the revisions available at the front desk if you are not an active
patient.
V. Complaints
If you are concerned that I have violated your privacy rights, or you disagree with a decision I made about access to your records, you may contact, the office manager at 678-749-7600.
VI.Effective Date, Restrictions, and Changes to Privacy Policy
This notice will go into effect on 4-14-2003.
I will limit the uses or disclosures that I will make as follows:
I reserve the right to change the terms of this notice and to make the new notice provisions effective for all PHI that I maintain. I will provide you with a revised notice by posting the revised
notice in the office, giving you a copy at the next appointment, or having available copies for you to request if you are not an active patient.

Happy holidays!

Holiday season is almost here. I want to thank you all for your support and encouragement, couldn't have done it without you.

Here's wishing you and yours a Blessed Christmas and Awesome Holidays!

XOXO
Ivy

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posted by Isaac Hobart at 8:35 AM