I understand that as part of my healthcare, Shrink Savannah originates and maintains health records describing my health history, symptoms, examination and test results, diagnoses, treatment and any plans for future care or treatment.

I understand this information serves as:

• A basis for planning my care and treatment
• A means of communication among the many health professionals who contribute to my care
• A source of information for applying my diagnosis and treatment to my bill
• A means by which a third-party payer can verify that services billed were actually provided
• A tool for routine healthcare operations such as assessing quality and reviewing the competence of healthcare professionals

Additionally:

• I understand and have been provided with a Notice of Privacy Practices for Protected Health Information that provides a more complete description of information uses and disclosures.
• I understand that I have the right to review the notice prior to signing this consent.
• I understand that Shrink Savannah reserves the right to object to the use of my health information at your request.
• I understand that I have the right to object to the use of my health information for directory purposes.
• I understand that I have the right to request restrictions as to how my health information may be used or disclosed to carry out treatment, co-payment, or healthcare operations and that Shrink Savannah is not required to agree to the restrictions requests.
• I understand that I may revoke this consent in writing, except to the extent that the office of Shrink Savannah has already taken action in reliance thereon.
• Patients of Gab Paderewski are overseen by Margaret Wheble, LCSW.

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU MAY HAVE ACCESS TO THIS INFORMATION

RIGHT TO NOTICE
As a patient, you have the right to adequately notice of the uses and disclosures of your protected health information. Under the Health Portability and Accountability Act (HIPAA), Shrink Savannah, can use your protected health information for treatment, payment and health care operations.

MARKETING
We will not use your health information for marketing communications without your authorization.

REQUIRED BY LAW
We may also use or disclose your health information when we are required to do so by law.

ABUSE OR NEGLECT
We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the victim of any other crime. We may disclose your health information to the extent necessary to avert a serious threat to your or other individual’s health or safety.

APPOINTMENT REMINDERS
We may use or disclose your health information to provide you with appointment reminder via phone, e-mail, letter or mobile text message.

YOUR RIGHTS AS A PATIENT
You have the right to

• restrict the disclosure of your protected health information (in writing). The request for restriction may be denied if the information is required for treatment, payment or health care operations.
• receive confidential communications regarding your protected health information.
• inspect and discuss your protected health information.
• amend your protected health information. Shrink Savannah has the right to refuse your amendment.
• receive an account of disclosures of your protected health information.

FRIENDS AND FAMILY MEMBERS
Please list any friends or family members that you are granting Shrink Savannah permission to discuss your health care information with, including but not limited to, schedule appointments, billing, diagnosis and treatment information.

LEGAL REQUIREMENTS
By law, we must abide by the terms of this Notice of Privacy Practices until we choose to change it. We reserve the right to change this notice at any time in compliance with and as allowed by the law. If we change this notice, the new privacy practices will apply to your health information that we already have, as well as to such information that we may generate in the future. If we change our privacy practices the new practices will be provided to you at your next scheduled appointment.

COMPLAINTS
If you have complaints regarding the way your protected health information was handled, you may submit a complaint in writing to our office. Confidential complaints in writing should be emailed to abrock@shrinksavannah.com.

Shrink Savannah is dedicated to protecting your privacy. While the law requires us to give you this disclosure, please understand that we have, and always will, respect the privacy of your health information.

There are circumstances in which we may have to use or disclose your health care information.

• We may have to disclose your health information to another healthcare provider or a hospital if it is necessary to refer you for the diagnosis, assessment or treatment of your health condition.
• We may have to disclose your health information and billing records to another party if they are potentially responsible for the payment of our services.
• We may need to use your health information within our practice for quality control or other operational purposes such as recall notices, reminder calls and treatment news.
• We are required by law to disclose your information in the event that you become suicidal and/or homicidal.
• All health and patient information disclosed to Shrink Savannah and its employees or staff shall remain confidential and we will ensure that we are in compliance with all federal and state laws pertaining to the confidentiality of patient health information, including HIPAA.

YOUR RIGHT TO LIMIT USES OR DISCLOSURES
You have the right to request that we do not disclose your health information to specific individuals, companies or organizations.

If you would like to place any restrictions regarding use or disclosure of your health information, please inform Shrink Savannah in writing. We are not required to agree to your restrictions, however we are bound to the restrictions you set if we are in agreement with them.

YOUR RIGHT TO REVOKE YOUR AUTHORIZATION
You may revoke any of your authorizations at any time; however your revocation must be in writing. We will not be able to honor a revocation request if we have already released your health information before we receive your written request to revoke your authorization. If you were required to give authorization as a condition of obtaining insurance, the insurance company may have a right to your health information if they decide to contest any of your claims.

I HEARBY AUTHORIZE THE FOLLOWING PEOPLE TO OBTAIN AND DISCUSS MY MEDICAL INFORMATION:

All new and existing patients are encouraged to review our office policies and procedures carefully. Our administrative team is always able to assist you with any questions or concerns.

Shrink Savannah is open Monday - Thursday from 8:30 a.m. - 4 p.m. and Friday from 8 a.m. to 3 p.m. The office is closed daily from 12:00 - 1:00 p.m. A provider is available after-hours via an answering service.

CANCELLATION / MISSED APPOINTMENT POLICY
We reserve your appointment time specifically for you and you alone. For this reason, our office charges for cancellations without 24 hours notice. A credit or debit card is required to be on file for all patients. In the event of a missed appointment, your card on file will be charged the full amount for your missed appointment. Your insurance company will not pay for missed appointment charges. Notifications for missed appointments are accepted via voicemail, website form and email but must be received within 24 hours of the scheduled appointment.

If you arrive late for your appointment and your provider determines that there is enough time remaining, he or she will be able to see you only for the allotted time left of your scheduled appointment. At such times, it may be necessary to schedule an additional appointment to allow you and the provider sufficient time to address your treatment concerns.

SPECIAL NEEDS FORMS
All medical forms (such as disability forms, school forms, letters) are completed by your provider while he or she meets with you in your ses- sion. Please notify your provider at the beginning of each session if you have forms to be filled out. Please be advised there may be additional fees for these documents determined by your provider.

Regular attendance at appointments is a critical part of your care. If you need a refill before your next scheduled appointment please contact your pharmacy to request. Although regularly scheduled visits with your doctor may at times feel burdensome, this commitment ensures that you will receive the highest level of care. Should you run out of your medication due to a missed or rescheduled appointment, your provider may choose to provide you enough medication to last until your next scheduled appointment.

PHONE CALLS AND DIRECT CORRESPONDENCE WITH YOUR PROVIDER
Phone conversations with your provider may incur fees. Scheduled phone appointments are charged the full amount of a regular office visit and are not billed with insurance. Quick updates and questions may be provided/answered through the office administrative team. Providers may receive email via info@shrinksavannah.com or by using the form on our website, ShrinkSavannah.com and selecting your provider from the dropdown menu. If a phone call with your provider lasts more than 10 minutes, the provider may charge you up to the full rate of an office visit.

INSURANCE
Your insurance is filed as a courtesy to you. It is your responsibility to be familiar with and to verify your mental health benefits and eligibility.

It is the patient’s responsibility to inform Shrink Savannah if your insurance company changes or has special requirements such as pre-certification, specific labs or designated hospitals.

FORMS OF PAYMENT
Shrink Savannah accepts payment in cash or major credit cards: Visa, Mastercard, American Express and Discover. Personal checks and money orders are not accepted.

I understand that telehealth is the practice of delivering clinical health care services via technology assisted media or other elec- tronic means between a practitioner and a client who are located in two different locations.

I understand that there will be no recording of any of the online sessions by either party. All information disclosed within sessions and written records pertaining to those sessions are confidential and may not be disclosed to anyone without written authorization, except where the disclosure is permitted and/or required by law.

I understand that I have the right to withdraw consent at any time without affecting my right to future care, services, or program benefits to which I would otherwise be entitled.

I understand that there are risks, benefits, and consequences associated with telehealth, including but not limited to, disruption of transmission by technology failures, interruption and/or breaches of confidentiality by unauthorized persons, and/or limited ability to respond to emergencies.

I agree to use the video-conferencing platform selected for our virtual sessions via a webcam or smartphone, and the provider or office Administrative team will explain how to use it.

I understand it is important to be in a quiet, private space that is free of distractions (including cell phone or other devices) during the session.

I understand it is important to use a secure internet connection rather than public/free Wi-Fi.

I understand I need to be on time and if I need to cancel or change my telehealth appointment, I must notify Shrink Savannah at least 24 hours in advance by phone or through the website form at ShrinkSavannah.com.

I will provide an alternate phone number where I can be reached to re-start the session in the event of technical problems.

I understand the need for a safety plan that includes at least one emergency contact and the closest emergency room to my location, in the event of a crisis situation.