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Henry Elder MD, Psychiatry |
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Henry Elder, MD Corvallis Psychiatry 2045 NW Grant Ave Corvallis Fax 866-391-7464 Corvallis Psychiatry has my permission to release to, and receive information from: (Person, place, or company):
___________________________________________________ further, I request that all information pertinent to my mental health care be communicated to Dr. Elder in order to improve coordination of care. Other purpose:____________________________
All of the records from Corvallis Psychiatry and those requested are or include "mental healthrecords". The following types of records that may be shared, including information about drug and alcohol use and HIV/other infectious diseases: · Chart notes from visits here or at requested source · Laboratory test results · Medication records
I understand I may revoke this permission at any time, though this would not affect information already released. (Unless you revoke it earlier in writing, we may release information to the person or organization named here until 180 days after your case closes with us.) I understand that once the information is disclosed pursuant to this authorization, it may be re-disclosed by the recipient without the knowledge or consent of Dr. Elder or you. This information may not be protected by Federal privacy regulation. (Though Federal regulations say you must be informed that release of your records to other individuals may occur, Dr. Elder will not release others' records to a second requestor.)
I specifically give authorization to fax information, and I understand the additional risk of loss of confidential information. A confidentiality statement will be included with such faxed information. I may request and receive a copy of this release.
PLEASE PRINT YOUR NAME:___________________________ DOB:_________________
PLEASE SIGN YOUR NAME:___________________________________DATE:____________
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RELEASE: You may use the following release to obtain records from primary care doctors or other psychiatrists or counselors to aid in evaluation at your first visit: please send it yourself to them. OTHER INFO: You may also READ the information (financial agreement, HIPAA) following that release prior to being seen (no need to copy and complete before meeting: we will ask you to sign an electronic version of those documents in the office) Additionally, there is registration form with insurance information, etc.
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This will formally register your understanding of and your agreement to those policies. The first appointment scheduled will start the formal doctor-patient relationship, and is an hour long. Dr. Elder will supply a report of our visits to your primary care doctor so that he or she is aware of what he has prescribed or advised. If that is not your wish, please let us know. No one else will receive information from our visit unless you release it, or as the law dictates, it is necessary to suspend confidentiality in order to save your life or that of another person. Please read the following and sign an electronic copy, stating that you will abide by this financial agreement: · I agree to your rates (Not listed on this public site— your insurance may specify rates) · I agree to release and assign payments from the insurance company to Dr. Elder and agree to release of information necessary to process that claim. · I understand I am responsible for fees for all services provided, and those necessary for collection of delinquent amounts. (Dr. Elder bills primary insurances as a courtesy service, which delays payments, sometimes for months, and is uncertain in many cases.) · I will come to each appointment prepared to make co-payments or deductible payments before each session. · I agree I will pay the prior notification charge if I miss or fail to notify of unattended meetings with 24 hours of notice. That charge will be $60, and cannot be billed to insurance. HIPAA A federal Act called HIPAA requires that you be given information about how your personal health information is handled. The Act requires so much information, in fact, that it’s hard to swallow all at once. This notice will tell you about the things you really need to know, while staying short enough that I hope you’ll actually read and understand it. #1. A record will be made of what we talk about. You are encouraged to take a copy. There is no other record. You can request corrections or additions, just ask. You can be in charge of sending the record to other doctors or anyone else who tells you or me they want it. I will not send it out, or provide information about you to someone on the phone, without your written permission. (I do routinely take information without a “release”, using care not to reveal information in the process; for example, family members may send email or leave voicemail about you if they wish.) There are exceptions to this: LEGAL: a court may subpoena your records, which means they are forcing me to give information about you, which may include talking to an opposing attorney. You get to object first, in court if necessary. The HIPAA rule also says “law enforcement” may request information for public safety purposes: these requests will be handled with wisdom and appropriate restraint. DANGER: if you or someone else is in danger, a health provider is required to reveal information about you if it is thought necessary to protect you or another person. #2. A large number of people may handle the paperwork associated with your insurance claims. However, there is generally no reason for these people to look at or ask for any details about your situation. They will see a diagnosis and evidence of treatment only. A few will see more information, including your symptoms, medications, and response to treatment (the “utilization review” people). As often as possible these people will see only information with your name, address, etc. removed from it. There is more to this story, including information about how electronic transfers of information are to be protected. Read more on the HIPAA website under "Privacy, Security, and Confidentiality." You may write concerns to us or to the government: write the Secretary of the Department of Health and Human Services, 200 Independence Ave S.W., Washington, D.C. 20201. You may request more information if this is not enough to satisfy your concerns.
__________________________________________________________________________ PRINT NAME SIGN NAME DATE
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