General Information

Information regarding your health care, including payment for health care, is protected by two federal laws: The Health Insurance Portability and Accountability Act of 1996 (HIPAA), 42 U. S. C. 132 d et seq., 45 C.F.R Parts 160 & 164, and the Confidentiality Law, 42 U.S.C 290dd-2, 42 C.F.R Part 160 & 164, and the Confidentiality Law, 42 U.S.C 290dd-2, 42 C.F.R Part 2. Under these laws, Applied Behavioral Sciences. (ABS) may not say to a person outside of ABS that you attend the program, nor may ABS disclose any information identifying you, or disclose any other protected information except as permitted by federal law.

ABS must obtain your written consent before it can disclose information about you for payment purposes. For example, ABS must obtain written consent before it can disclose information to your health insurer in order to be paid for services.

Generally, you must also sign a written consent before ABS can share information for treatment purposes or for health care operations. However, federal law permits ABS to disclose information without your written permission:
1. Pursuant to an agreement with a business associate;
2. For research, audit or evaluations;
3. To report a crime committed on ABS’s premises or against ABS personnel;
4. To medical personnel in a medical emergency;
5. To appropriate authorities to report suspected child abuse or neglect;
6. As allowed by a court order For example, ABS can disclose information without your consent to obtain legal or financial services, or to another medical facility to provide health care to you, as long as there is a business associate agreement in place.

Before ABS can use or disclose any information about your health in a manner, which is not described above, it must first obtain your specific written consent allowing it to make the disclosure. Any such written consent may be revoked by you in writing.

Your Rights Under HIPAA you have the right to request restrictions on certain uses and disclosures of your health information.

ABS is not required to agree to any restrictions you request, but if it does agree then it is bound by that agreement and may not use or disclose any information which you have restricted except as necessary in a medical emergency.

You have the right to request that we communicate with you by alternative means or at an alternative location. ABS will accommodate such requests that are reasonable and will not request an explanation from you.

Under HIPAA you also have the right to inspect and copy your own health information maintained by ABS, except to the extent that the information contains psychotherapy notes or information compiled for use in a civil, criminal, or administrative proceeding or in other limited circumstances.

Under HIPAA you also have the right, with some exceptions to amend health care information maintained by ABS’s records, and to request an receive an accounting of disclosures of your health related information made by ABS during the six years prior to our request.

You also have the right to receive a paper copy of this notice.

ABS’s Duties ABS is required by law to maintain the privacy of your health information and to provide you with notice of its legal duties and privacy practices with respect to your health information. ABS is required by law to abide by the terms of this notice. ABS reserves the right to change the terms of this notice and to make new notice provisions effective for all protected health information it maintains.

Your primary counselor will provide you with a copy of any and all changes made to this notice.

Complaints and Reporting Violations You may complain to the Program Director of ABS and the Secretary of the United States Department of Health and Human Services if you believe that your privacy rights have been violated under HIPAA. You will not be retaliated against for filing such a complaint.
Contact - For further information contact the program director at info@absbehavioralhealth.com

I understand the content within this notice. I will receive a copy for my records after my first appointment.  
  Signature *    

I,    First Name *     Last Name * , authorize Applied Behavioral Sciences, LCSW, PC (ABS) 

The purpose of the disclosure authorized in this consent is to:

To communicate with and disclose to one another the above information for progress reporting and compliance purposes:

I, understand that my treatment records are protected under federal regulations governing confidentially and The Health Insurance Portability and Accountability Act of 1996 (“HIPPA”), 45 C.F.R. Pts 160 & 164 and cannot be disclosed without my written consent unless otherwise provided for regulations. I also understand and that in any event, this consent expires automatically as follows: One year after last day of service

1. If I am authorizing the release of HIV-related, alcohol or drug treatment, or mental health treatment information, the recipient is prohibited from re-disclosing such information without my authorization unless permitted to do so under federal or state law. I understand that I have the right to request a list of people who may receive or use my HIV-related information without authorization. If I experience discrimination because of the release or disclosure of HIV-related information, I may contact the New York State Division of Human Rights at (212) 480-2493 or the New York City Commission of Human Rights at (212) 306-7450. These agencies are responsible for protecting my rights.
2. I have the right to revoke this authorization at any time by writing to the program director at ABS. I understand that I may revoke this authorization except to the extent that action has already been taken based on this authorization.
3. I understand that signing this authorization is voluntary. My treatment, payment, enrollment in a health plan, or eligibility for benefits will not be conditioned upon my authorization of this disclosure.
4. Information disclosed under this authorization might be redisclosed by the recipient (except as noted above in Item 2), and this redisclosure may no longer be protected by federal or state law.
5. The authorization does not authorize ABS to discuss my health information or medical care with anyone other than the individual, attorney, law firm or governmental or social service agency or other organization specified above. 

I understand that generally ABS may not condition my treatment on whether I sign a consent form, In certain limited circumstances I may be denied treatment if I do not sign a consent form.


Date *    
Patient Signature *  
Guardian Signature