four winds saratoga adolescent intensive outpatient program important … · four winds saratoga...

Four Winds Saratoga ● 30 Crescent Avenue, Saratoga Springs, NY 12866 ● 518-584-3600 ● www.fourwindshospital.com

Four Winds Saratoga

Adolescent Intensive Outpatient Program

Important Forms, Insurance and Scheduling Information Prior to Your First Visit We have attached a number of forms that you should complete at home and bring with you to your evaluation appointment. If you do not have time to complete them prior to your first visit, please arrive at the office 15 minutes early so that the forms can be filled out at that time. The policy holder of the insurance must sign these forms. Included you will find:

Patient Information and Consent Patient Clinical Information

Authorizations for Release of Information: ○ Medical Doctor/PCP ○ Therapist ○ Psychiatrist ○ School ○ Pharmacy

Also included in this packet are the Patient Bill of Rights and Notice of Privacy Practices. These forms are for you to review and to keep.

A parent or guardian should plan to accompany the teenager to the evaluation in order to obtain a comprehensive history. We understand that this is not always possible, but it is necessary that at least one parent/guardian must attend with your child. Insurance and Billing Information Please bring your insurance card to the first visit so that we can make a copy. Your co-payment or full payment, if required, is always due at the time of service. Cancellation and Contact Information If you are unable to attend your evaluation and need to reschedule, or if you have any questions about billing, insurance or the program, please call us so that we may assist you. Our voicemail system is available 24-hours every day, so please feel free to call us, anytime, at 518-584-3600, dial ext. 3342 or ask for the “Adolescent Intensive Outpatient Program”, and then follow the prompts. Calls will be returned to you during our office hours: Monday – Friday from 8 a.m. – 5 p.m.

Rev: 7/18/08, 3/12/12, 1/13

I03-AIOP-010

PATIENT INFORMATION

Date: _____________________ MRN: ____________ (Office Use Only)

Patient’s Name:___________________________________ Date of Birth: ______________ Age:______

Sex: ____ Male ____ Female Patient’s Social Security Number: _____-_______-________

Street Address _____________________________________________________________ Apt# ______

City: ________________________________ State____________ Zip Code:__________ County: ________

Patient’s Home Phone Number: ( ) ________________________ Okay to call: ___ Yes ___ No

PARENT INFORMATION / PERSONS TO BE CONTACTED IN CASE OF EMERGENCY:

Mother’s or Father’s Name: _________________________________ Relationship: _______________

Address (if different): ___________________________________________________________________

Home Phone:( )______________ Work Phone:( )______________ Cell Phone: ( )______________

Other Parent’s or Contact’s Name : ___________________________ Relationship:_________________

Address (if different): ____________________________________________________________________

Home Phone:( )______________ Work Phone:( )______________ Cell Phone: ( )______________

Primary Care Physician: _____________________________ Phone Number: ( )__________________

Address:

INSURANCE INFORMATION:

Primary Insurance: ________________________ Policy #: _________________Group #: __________

Subscriber’s Name: ________________________________ Subscriber’s Date of Birth: _____________

Subscriber’s Social Security # _____-_______-________ Relationship to Patient: ____________

Subscriber’s Address (if different than patient):

Subscriber’s Employer:

Secondary Insurance: _______________________ Policy #: _________________Group #: __________

Subscriber’s Name: ________________________________ Subscriber’s Date of Birth: _____________

Subscriber’s Social Security # _____-_______-________ Relationship to Patient: ____________

Subscriber’s Address (if different than patient):

Subscriber’s Employer:___________________________________________________________________

RELEASE OF INFORMATION I authorize the release of information for claims, certification/case management/quality improvement, and other purposes related to the

benefits of my Health Plan. (Releasing information to providers, family, etc., requires separate forms).

I understand and agree to all of the information above.

_______________________________ /_____________________________ _________ __________________ ________

Patient, if 18 or older Signature Printed Name Date Witness Date

_______________________________ /_____________________________ _________ __________________ ________

Parent (or Guardian) Signature Parent (or Guardian) Printed Name Date Witness Date

Rev: 7/18/08, 3/12/12, 1/13

I03-AIOP-023

CONSENT AND POLICY ACKNOWLEDGEMENT

Please read and sign below to show your understanding and agreement to the following contract terms:

CONSENT FOR TREATMENT I authorize and request that Four Winds - Saratoga carry out psychological examinations, treatments, and/or

diagnostic procedures, which now or during the course of my care as a patient my physician deems advisable. I

understand that the purpose of these procedures will be explained to me and that I will have an opportunity to ask

questions. I understand that I can revoke my consent at any time.

CONFIDENTIALITY I have received a copy of the Four Winds – Saratoga Patient Bill of Rights and the Notice of Privacy Practices.

I hereby consent to the taking of my/my child’s photograph for identification purposes only. I understand that, upon

discharge, my photograph will be kept by Four Winds – Saratoga and filed in my medical record.

FINANCIAL TERMS I understand that upon verification of health plan/insurance coverage and policy limits, my insurance carrier will be

billed and Four Winds - Saratoga will be paid directly by the carrier. I agree that I am responsible for the full

payment, if I am not eligible at the time services are rendered. I understand that deductibles, co-payments and/or

outstanding balances are always due at the time of service. I will incur a Billing Service Fee of $10 whenever a co-

payment is not paid at the time of service. I will incur a Returned Check Fee of $20 on any bounced check.

APPEALS AND GRIEVANCES I understand that I have the right to submit a complaint or grievance to Four Winds-Saratoga with respect to any

aspect of the care provided. Further, I risk nothing in exercising this right. Complaints or grievances may be

expressed in person or if I prefer I may put my concern in writing. Forms for written complaints and grievances are

available at the receptionist’s desk.

ASSIGNMENT OF BENEFITS I, the undersigned, certify that I (or my dependent) have the above insurance coverage and I assign directly to Four

Winds - Saratoga the right to payment under such insurance benefits. I understand that I am financially responsible

for all charges for services rendered, whether or not paid by insurance.

I have read and understand the terms set forth above.

_______________________________ /_____________________________ _________ __________________ ________ Patient, if 18 or older Signature Printed Name Date Witness Date

_______________________________ /_____________________________ _________ __________________ ________ Parent (or Guardian) Signature Parent (or Guardian) Printed Name Date Witness Date

Rev. 07/14/09, 02/09/12, 11/2017 CD7-IP-033

Patient’s Name:

FAMILY MEDICAL QUESTIONNAIRE ONGOING MEDICAL PROBLEMS

Patient’s Date of Birth:

Name of Your Child’s Primary Medical Provider:

Phone Number:

Date of Last Visit to Your Child’s Primary Medical Provider:

Reason for this Visit:

HAS YOUR CHILD EVER HAD: COMMENTS Chicken Pox Illness Yes No Chicken Pox Vaccine Yes No Asthma Yes No Allergies Yes No High Blood Pressure Yes No Heart Condition or Murmur Yes No Head Injury Yes No Diabetes Yes No Seizures/Convulsions Yes No Tuberculosis or Positive Skin Test Yes No Undescended Testicles Yes No Last Menstrual Period/Age at 1st Period Yes No Eye/Ear/or Speech Problem Yes No List Any Surgeries or Hospitalization Your Child Has Had:

CHECK AND EXPLAIN ANY OF THE FOLLOWING CURRENT OR ONGOING PROBLEMS: Weight Loss Yes No Weight Gain Yes No Sore Throat Yes No Frequent Headaches Yes No Skin Rashes/Eczema Yes No Difficulty Breathing Yes No Cough Yes No Sinus Problems Yes No Diarrhea Yes No Constipation Yes No Vomiting Yes No Problems With Urination Yes No Bedwetting Yes No Joint Problems or Pain Yes No OTHER:

Please continue on to the back of the form.

Rev. 07/14/09, 02/09/12, 11/2017 CD7-IP-033

DEVELOPMENTAL HISTORY YES NO 1. Were there problems in pregnancy, labor, or delivery?

If yes, what happened?

2. Did the mother use cigarettes, drugs or alcohol during pregnancy?

3. Did your child experience any problems during the first year?

If yes, please describe.

4. Do you believe your child’s development was normal?

If no, why?

5. At what age did your child first walk? At what age did your child first use words correctly?

MEDICATIONS/ALLERGIES 6. What medication(s) is your child currently taking?

7. Is your child allergic to anything? Yes No

If yes, what?

MEDICAL HISTORY 8. Do you believe you child is healthy? Yes No If no, why?

9. Are your child’s immunizations (shots) up-to-date? Yes No Does your child attend school in NYS? Yes No 10. Has your child ever been hospitalized overnight or longer? Yes No

If yes, when and for what reason?

11. Your child’s dentist is: 12. Date of last dental check-up:

TB RISK FACTOR SCREENING 1) Any history of foreign of birth or travel greater than a three month stay in a country with higher risk of TB than the USA?

Yes No If so, which country or countries:

2) Any history of close contact with a person diagnosed with active TB?

Yes No Relationship: When:

3) Any current symptoms of TB (i.e., cough greater than two weeks, unexplained weight loss, night sweats or bloody sputum).

Yes No If yes, give details:

Signature: Relationship to Patient: Date:

Physician/NPP/FNP Signature: Title: Date: Time:

FOR CLINIC USE ONLY Date:_________

Time:_________ AM / PM Reviewed by:___________________________

MEDICATION QUESTIONNAIRE

Name: Date: Date of Birth:

Rev. 08/05/10, 1/30/2012, 8/13, 11/16, 3/17 CD9-IP-057 1

DIRECTIONS: Please place a check mark in the box that describes your experience with any of the medications listed below.

Generic Name Trade Name

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Patient, Parent, Guardian or

Physician/NPP Comments

ANTIDEPRESSANTS Amitriptyline Elavil Bupropion Wellbutrin, Wellbutrin SR,

Wellbutrin XL

Citalopram Celexa Clomipramine Anafranil Desipramine Norpramin Desvenlafaxine Pristiq Doxepin Sinequan, Silenor Duloxetine Cymbalta Escitalopram Lexapro Fluoxetine Prozac, Sarafem Fluvoxamine Luvox, Luvox CR Imipramine Tofranil Isocarboxazid Marplan Levomilnacipran Fetzima Milnacipran Savella Mirtazapine Remeron, Remeron SolTab Nefazodone Serzone Nortriptyline Pamelor Paroxetine Paxil, Paxil CR Phenelzine Nardil Selegiline Transdermal Emsam Sertraline Zoloft Tranylcypromine Parnate Trazodone Desyrel, Oleptro Venlafaxine Effexor, Effexor XR Vilazodone Viibryd Vortioxetine Trintellix, Brintellix ANTIPSYCHOTICS “major tranquilizers” Aripiprazole Abilify Asenapine Saphris Brexpiprazole Rexulti Cariprazine Vraylar Chlorpromazine Thorazine Clozapine Clozaril, Fazaclo, Versacloz Fluphenazine Prolixin, Prolixin Decanoate Haloperidol Haldol, Haldol Decanoate Iloperidone Fanapt



Rev. 08/05/10, 1/30/2012, 8/13, 11/16, 3/17 CD9-IP-057 2

Generic Name

Trade Name

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Loxapine Loxitane Lurasidone Latuda Molindone Moban Olanzapine Zyprexa, Zyprexa Zydis, Zyprexa

Relprevv

Paliperidone Invega, Invega Sustenna, Inrega Trinza

Perphenazine Trilafon Pimavanserin Nuplazid Quetiapine Seroquel, Seroquel XR Risperidone Risperdal, Risperdal Consta,

Risperdal M-Tab

Thioridazine Mellaril Thiothixene Navane Trifluoperazine Stelazine Ziprasidone Geodon ANXIOLYTICS “anti-anxiety” “minor tranquilizers” Alprazolam Xanax, Xanax XR Buspirone BuSpar Chlordiazepoxide Librium Clonazepam Klonopin, Klonopin Wafers Clorazepate Tranxene Diazepam Valium Hydroxyzine Vistaril, Atarax Lorazepam Ativan Oxazepam Serax ANTICHOLINESTERASE/ALZHEIMER’S AGENTS Donepezil Aricept Galantamine Razadyne Memantine Namenda, Namenda XR Rivastigmine Exelon Selegiline Eldepryl Tacrine Cognex ALCOHOL/DRUG/SMOKING CESSATION AGENTS Acamprosate Campral Buprenorphine/ Naloxone

Suboxone, Bunavail, Zubsolv

Bupropion Zyban Disulfiram Antabuse Methadone Dolophine Naltrexone ReVia, Vivitrol



Rev. 08/05/10, 1/30/2012, 8/13, 11/16, 3/17 CD9-IP-057 3

Generic Name Trade Name

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Varenicline Chantix MOOD STABILIZING AGENTS/AED’s Carbamazepine Tegretol, Tegretol XR Fluoxetine/Olanzapine Symbyax Gabapentin Neurontin Lamotrigine Lamictal, Lamictal XR, Lamictal

ODT

Levetiracetam Keppra, Keppra XR Lithium Eskalith, Eskalith CR, Lithobid Oxcarbazepine Trileptal Tiagabine Gabitril Topiramate Topamax Valproate Depakene, Depakote, Depakote

ER, Valproic Acid

PSYCHOSTIMULANTS Amphetamine Salts Adderall, Adderall XR Atomoxetine Strattera Dexmethylphenidate Focalin, Focalin XR Dextroamphetamine Dexedrine, Dextrostat Armodafinil Nuvigil Lisdexamfetamine Vyvanse Methylphenidate Ritalin, Ritalin SR, Ritalin LA,

Concerta, Metadate ER/CD, Methylin, QuilliChew ER, Quillivant XR

Methylphenidate Transdermal

Daytrana

Modafinil Provigil SEDATIVE/HYPNOTICS Chloral Hydrate Noctec Eszopiclone Lunesta Flurazepam Dalmane Ramelteon Rozerem Suvorexant Belsomra Temazepam Restoril Triazolam Halcion Zaleplon Sonata Zolpidem Ambien, Ambien CR,

Intermezzo, Edluar

OTHER Benztropine Cogentin Clonidine Catapres, Kapvay Cyproheptadine Periactin



Rev. 08/05/10, 1/30/2012, 8/13, 11/16, 3/17 CD9-IP-057 4

Diphenhydramine Benadryl Guanfacine Tenex, Intuniv Prazosin Minipress Propranolol Inderal Trihexyphenidyl Artane HERBAL PREPARATIONS

I am unable or unwilling to complete this form. I have completed this form to the best of my ability. Signature of Patient/Parent/Guardian: Date:

Reviewed in person with the patient. Reviewed over the phone with the parent/guardian of the patient. Reviewed in person with the patient and/or parent/guardian of the patient.

Signature of Psychiatrist/NPP: Date/Time:

CD30-MRD-004

Rev. 3/11/03, 4/16/03, 4/17/03, 5/6/03, 7/14, 5/15

AUTHORIZATION FOR

RELEASE OF INFORMATION

Patient Name__________________________

Date of Birth _________________________

FOUR WINDS SARATOGA

30 CRESCENT AVENUE

SARATOGA SPRINGS, NEW YORK 12866

PHONE: (518) 584-3600 FAX: (518) 580-1514

I authorize Four Winds Saratoga to obtain from or release to any

Person/Program within the Organization/Facility/Program(s)

listed below

Person/Agency:

Address:

City, State, Zip:

Covering the period of healthcare: last 1 yr or last 2 yrs or

From date _______________ to date _________________

Phone: Fax:

Obtain Release

Diagnosis Only

Dates of Admission and Discharge

Integrated Assessments/Suicide Risk and

Substance Abuse Assessments

Clinical Discharge Summary

Verbal/Written Communication for Discharge

Medical: H&P, Labs, EKG, Immunizations, etc.

Progress Notes

Obtain Release

School Discharge Summary/Educational

Materials/Verbal Academic Reports

Medication Information only

Billing Issues & Payment Arrangements

Applications

Psychological Testing

Other(Specify):_________________________

Whole Record (a fee of $0.75/page may be applied)

This information will be used for the following purpose(s):

Evaluation and Continuing Treatment Coordinating Care

Educational Placement/Other Educational Concerns/Billing School District for Education

Insurance Eligibility/Benefits/Claims Resolution

Legal Other (specify): I understand that I have the right to revoke this authorization at any time, by submitting a revocation in writing to the Health

Information Management. The revocation will not apply to information that has already been released in response to this

authorization. I also understand that the revocation will not apply to my insurance company when the law provides my insurer with

the right to contest a claim under my policy. This authorization will expire in one year from the date of the signature below and

may be used until such time for either a one time release or periodic release of information.

If the disclosure is for educational purposes, I understand that the recipient may be my child’s home school district and any school

within the home school district. Disclosure to any other school or educational entity requires a separate authorization.

I understand that authorizing the disclosure of this information is voluntary. I understand that I can refuse to sign this authorization

and that my refusal to sign will not affect my ability to obtain treatment. I understand that I have a right to receive a copy of this

authorization. I understand that any disclosure of information carries with it the potential for an unauthorized re-disclosure by the

recipient, and the information may not be protected by the federal privacy rules or by New York State law.

Signature of Patient or Legal Guardian Date

If Signed by Legal Guardian, Relationship to Patient Signature of Witness (over the age of 18)

TO CANCEL PERMISSION OR REFUSE DISCLOSURE OF RECORDS FILL OUT THE INFORMATION BELOW

I hereby cancel my permission to release information to the

above named person or entity.

I hereby refuse to authorize the release of information to the

above named person or entity.

Signature of Patient or Legal Guardian Date

PATIENT’S BILL OF RIGHTS

Four Winds Saratoga

Revised: 6/2012, 11/2013, 1/2018

FWS-011

Page 1 of 4

Name: Date of Birth:

At the time of admission to an inpatient or outpatient program patient's rights are reviewed and

explained to the patient (and family, if appropriate) with respect to the care provided at a hospital

of the mentally ill, as well as hospital's rules and regulations. Only then is the patient's signature

and statement obtained on Admission Application and Status and Rights forms.

Four Winds-Saratoga patients shall be afforded the right to:

1. Considerate and respectful care in a manner that assures non-discrimination which

acknowledges and is respectful of their ethic and cultural environment;

2. Freedom from abuse and mistreatment;

3. The name of the physician responsible for coordinating his/her care;

4. The name and function of any person providing health care services to the patient;

5. Obtain from his/her physician complete current information concerning his diagnoses,

treatment and prognosis in terms the patient can be reasonably expected to understand. When

it is not medically advisable to give such information to the patient, the information shall be

made available to an appropriate person in his/her behalf;

6. Receive from his/her physician the information necessary to give informed consent prior to

the start of any procedure or treatment, or both, and which, except for those emergency

situations not requiring an informed consent, shall include as a minimum the specific

procedure or treatment, or both, the medically significant risks involved, and the probable

duration of incapacitation, if any. The patient shall be advised of medically significant

alternatives for care or treatment, if any;

7. Request a review of his/her medical record and receive a complete explanation of the

procedure(s) by which appropriate access to the medical record is obtained;

8. Refuse treatment to the extent permitted by law and to be informed of the medical

consequences of his/her action;

9. Privacy to the extent consistent with providing adequate medical care to the patient. This

shall not preclude discreet discussion of a patient's care or examination of a patient by

appropriate health care personnel;


Four Winds Saratoga

Revised: 6/2012, 11/2013, 1/2018

FWS-011

Page 2 of 4

10. Privacy and confidentiality of all records pertaining to the patient's treatment except as

otherwise provided by law or third party contract. When indicated, the patient's record shall

contain documentation that the rights of the patient and patient's families are protected;

11. A response by the hospital in a reasonable manner to the patient's request for service

customarily rendered by the hospital consistent with the patient's treatment;

12. A response by the hospital in a reasonable and timely manner to the patient's need for

appropriate medical care not customarily rendered by the hospital;

13. Be informed by his/her physician or delegate of the physician of the patient's continued

mental and physical health care requirements following discharge and that before transferring

a patient to another facility the hospital first inform the patient of the need for and alternative

to such a transfer;

14. A response by the hospital in a reasonable, timely manner to the patient's complaint of

physical pain, acute and chronic. Appropriate interventions, education and referral as

applicable.

15. The identity, upon request, of other health care and educational institutions that the hospital

has authorized to participate in his/her treatment;

16. Examine and receive an explanation of his/her bill, regardless of source of payment;

17. Know the hospital rules and regulations that apply to his/her conduct as a patient;

18. Services within the least restrictive environment as possible; to be informed/educated of

methods to assist in anger management, interventions to safety of self/others all in least

restrictive way.

19. An individualized treatment plan which is periodically reviewed;

20. Actively participate with their responsible parents or relatives in planning for treatment;

21. Request the opinion of a consultant at their own expense or request an in-hospital review of

the patient's individual treatment plan;

22. Receive a written statement of the patient's rights and a copy is posted in each patient unit;

23. Be informed of their rights in a language the patient understands;

24. The current and future use and disposition of products of audio-visual techniques;


Four Winds Saratoga

Revised: 6/2012, 11/2013, 1/2018

FWS-011

Page 3 of 4

25. To receive full explanation of any research project and the right to refuse participation in any

research project;

26. Be informed of the hospital's responsibility, when the patient refuses treatment, to seek

appropriate legal alternatives or orders of involuntary treatment with professional standards,

to terminate the relationship with the patient upon reasonable notification;

27. Be informed of the source of the facility's reimbursement and any limitations placed on the

duration of services;

28. Be informed of any changes in the professional staff responsible for the patient or any

transfer of the patient within or out of the hospital;

29. To initiate a complaint or grievance through the unit leadership and/or Director of Quality

Management, extension 3116.

30. Audio-visual equipment and other procedures where consent is required by law; no such

procedure shall be implemented without full consultation with the patient and/or family with

full explanation of the reasons and efficacy of such. The use of such techniques shall be

employed only in the service of augmented and/or enhanced patient care or for the purpose of

internal educative functions for the staff. In either case, following the appropriate

explanation, the patient has full right of refusal to participate in such procedures without

prejudice to his/he continued stay and treatment at the hospital. In all such cases, written

consent shall be obtained prior to implementation of such techniques.

31. Receive all necessary information concerning their rights under the New York State Health

Care Proxy Law and assistance by the hospital in completing all necessary procedures

relevant to his/her preferred advance directive(s).

32. Applies to Inpatient: Receive visitors, take telephone calls and send a receive mail unless

clinically contraindicated as designated by you (or legal guardian), including but not limited

to, a spouse, a domestic partner (including a same-sex domestic partner), another family

member, or a friend. Also included is the right to withdraw or deny such consent at any time.

33. Applies to Inpatient: Suitable areas for patients to visit in private are available, unless

clinically contraindicated;

34. You have the right to know the following:

Four Winds – Saratoga Hospital believes that you are entitled to make informed

decisions regarding your medical care. Medical staff, including nurses, clinicians

and physicians, are either present at the Hospital or available “on-call” by

telephone at all times. However, a physician is not on-site 24 hours per day, 7

days per week. If a medical emergency arises when a physician is not on-site, the


Four Winds Saratoga

Revised: 6/2012, 11/2013, 1/2018

FWS-011

Page 4 of 4

Hospital will initiate its Rapid Response protocol and provide treatment to the

patient, and if needed CPR and emergency transport to a local medical facility by

an ambulance service dispatched by phoning 911. The physician “on-call” will be

notified. The Hospital hereby notifies you that it meets the federal definition of a

physician-owned hospital, pursuant to 42 C.F.R Section 4893. The list of the

Hospital’s physician owners or investors is available to you upon request from

Jacqueline Gacek RN MS, the Hospital’s Director of Quality Management who

may be reached at 518-584-3600, ext. 3116.

35. Be informed of the address and phone numbers of the following agencies:

Mental Hygiene Legal Services

Mental Hygiene Legal Service

200 Great Oaks Blvd.

Suite 223

Albany, NY 12203

Phone: (518) 471-4870

Fax: (518) 451-8730

New York State Office of Mental Health

44 Holland Avenue • Albany, New York 12229

1-800-597-8481

En Espanol: 1-800-210-6456

TDD 1-800-421-1220 for people who are deaf or

hearing impaired

www.omh.state.ny.us <http://www.omh.state.ny.us

National Alliance for the Mentally Ill

260 Washington Avenue

Albany, New York 12210

462-2000

www.naminys.org <http://www.naminys.org

Division of Quality Assurance and Investigations

NYS Commission on Quality of Care and Advocacy

for Persons with Disabilities

401 State Street

Schenectady, New York 12305-2397

1-800-624-4143

www.cqc.state.ny.us <http://www.cqc.state.ny.us

The U.S. Department of Health and

Human Services

200 Independence Ave,. S.W.

Washington, D.C. 20201

1-877-696-6775

Office of Quality Monitoring

The Joint Commission

One Renaissance Blvd • Oak Brook Terrace, IL

60181

Toll Free: 1-800-994-6610

[email protected]

http://www.omh.state.ny.us/

http://www.naminys.org/

http://www.cqc.state.ny.us/

Notice of Privacy Practices (FWS-008) Page 1

Four Winds Saratoga 30 Crescent Avenue Saratoga Springs, NY 12866

518-584-3600 1-800-888-5448 www.fourwindshospital.com If you have any questions about this Notice please contact the Hospital’s Privacy Officer, Erin Dorflinger, LCSW-R , 518-584-3600 ext. 3286

Your Information. Your Rights. Our Responsibilities. This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

YYour Rights When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.

For certain types of disclosures of information in your medical record at a psychiatric hospital, New York State law may be more stringent than the federal law. For example the New York Mental Hygiene Law generally does not permit the disclosure of a clinical record except under circumstances specifically set forth in the law. The Hospital will follow New York law when it is more restrictive. Get an electronic or paper copy of your medical record

You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this.

We will provide a copy or a summary of your health information, usually within 10 days of your request. We may charge a reasonable, cost-based fee.

Ask us to correct your medical record You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this.

We may say “no” to your request, but we’ll tell you why in writing within 60 days.

Request confidential communications You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.

We will say “yes” to all reasonable requests. Ask us to limit what we use or share • You can ask us not to use or share certain health

information for treatment, payment, or our operations. • We are not required to agree to your request, and we may say “no” if it would affect your care. • If you pay for a service or health care item out-of-pocket


in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. • We will say “yes” unless a law requires us to share that information.

Get a list of those with whom we’ve shared information

• You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why. • We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide this accounting for free.

Get a copy of this privacy notice • You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.

Choose someone to act for you • If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. • We will make sure the person has this authority and can act for you before we take any action.

File a complaint if you feel your rights are violated

• You can complain if you feel we have violated your rights by contacting Erin Dorflinger, LCSW-R, at 518-584-3600 ext. 3147. • You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/. • We will not retaliate against you for filing a complaint.

Your Choices For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.

In these cases, you have both the right and choice to tell us to:

• Share information with your family, close friends, or others involved in your care

• Share information in a disaster relief situation

If you are not able to tell us your preference we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.

Our Uses and Disclosures How do we typically use or share your health information? We typically use or share your health information in the following ways. To treat you • We can use your health

information and share it with other professionals who are treating you.

Example: The psychiatrist treating you may ask your outpatient psychiatrist about your treatment.


Run our organization • We can use and share your health information to run our hospital, improve your care, and contact you when necessary.

Example: We use health information about you to manage your treatment and services.

Bill for your services • We can use and share your health information to bill and get payment from health plans or other entities.

Example: We give information about you to your health insurance plan so it will pay for your services.

How else can we use or share your health information? We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html. Help with public health and safety issues

• We can share health information about you for certain situations such as: • Preventing disease • Helping with product recalls • Reporting adverse reactions to medications • Reporting suspected abuse, neglect, or domestic violence • Preventing or reducing a serious threat to anyone’s health or safety

Do research • We can use or share your information for health research. All research projects for patients receiving psychiatric services are subject to a special approval process under New York law.

Comply with the law • We will share information about you if state or federal laws require it, including with the Department of Health and Human Services or the NYS Office of Mental Health if it wants to see that we’re complying with federal and/or state privacy law. • We can share health information about you in response to a court or administrative order, or in response to a subpoena. • For workers’ compensation claims • For law enforcement purposes or with a law enforcement official • With health oversight agencies for activities authorized by law • For special government functions such as military, national security, and presidential protective services.

Inmates If you are an inmate of a correctional facility, we may disclose medical information necessary for making a determination regarding your health care, security, safety or ability to participate in programs when the chief administrative officer of the facility has made a request for it.

Work with a medical examiner • We can share health information with a coroner or medical examiner when an individual dies.


Respond to organ and tissue donation requests

We can share health information about you with organ procurement organizations.

Other We do not create or manage a hospital directory. We do not contact patients for marketing or fundraising efforts.

Our Responsibilities • We are required by law to maintain the privacy and security of your protected health information. • We will let you know promptly if a breach occurs that may have compromised the privacy or

security of your information.

• We must follow the duties and privacy practices described in this notice and give you a copy of it.

• We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.

For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html. Changes to the Terms of This Notice We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our web site. Effective date of this Notice: 09/23/2013. This Notice of Privacy Practices applies to Four Winds Saratoga.

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