I authorize the following person/agency:
to release all health related records to Neuropsychology Associates of Fairfax, 3020 Hamaker Court Suite 103, Fairfax, VA 22031.
PLEASE NOTE: INSURANCE POLICIES DO NOT USUALLY COVER ANY SERVICES THAT ARE RELATED TO LEARNING DEVELOPMENTAL PROBLEMS OR EDUCATIONAL ISSUES, TESTING MAY INCLUDE THESE PROCEDURES - YOU ARE RESPONSIBLE FOR THESE CHARGES.
NEUROPSYCHOLOGY ASSOCIATES OF FAIRFAX, LLC
PATIENT INTAKE FORM
Neuropsychology Associates of Fairfax is mandated by The Affordable Care Act to collect the following information which will be used by HHS to collect demographic data on Healthcare delivery.
FOR MEDICARE PATIENTS ONLY: MEDIGAP INSURANCES
THIS NOTICE DESCRIBES HOW PROTECTED HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GAIN ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
This notice is first in effect on January 1, 2003.
This notice covers all information in our written or electronic records which concerns you, your health care, and payments for your health care. It also covers information we may have shared with other organizations to help us provide your care, get paid for providing care, or manage our administrative operations.
Neuropsychology Associates of Fairfax may use and disclose your protected health information (PHI) for : a. Treatment - i.e.; providing care services, sending information/coordinating care with other health care providers caring for you, ordering and obtaining off site tests/results, etc. b. Payment - i.e.; submitting insurance claims on your behalf for treatment rendered.c.Health care operations - i.e.; internal business planning activities and quality of care evaluation.
Neuropsychology Associates of Fairfax is permitted or required, under specific circumstances, to use or disclose protected health information without the individual's written authorization, including, but not limited to: a. Disclosures required by law (i.e. court or administrative orders, subpeona, discovery request or other lawful purposes). b. Disclosures to avert any serious threats to your health and safety or the health and safety of another person (i.e.: if we reasonable believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes) as mandated by law. c. Disclosures with reference to Workers' Compensation or Food and Drug Administration.
Neuropsychology Associates of Fairfax may contact the individual to provide appointment reminders or information about treatment or other health related benefits and services that may be of interest to the individual or patient. Neuropsychology Associates of Fairfax will routinely contact patients via telephone at home, cell, and/or work and, unless otherwise requested, may leave messages on the appropriate voicemail or answering service regarding appointments, test results, etc. We may also send faxes if you have designated this option. Please inform us if you do not want us to leave messages or restrict messages to a specific phone number.
Other uses or disclosures will be made only with the individual's written authorization, and the individual may revoke such authorization at any time.
Our patients have the following rights regarding their protected health information: 1. The right to request restrictions on certain uses and disclosures of PHI. However, we may not agree to all requested restrictions. 2. The right to restrict disclosures to your insurance company for health care items or services for which you have paid for in full at the time of service. 3. The right to receive confidential communications of protected health information, as applicable. 4. The right to inspect and copy protected health information, as provided in the Privacy Regulation. 5. The right to amend protected health information, as provided in the Privacy Regulation. 6. The right to receive an accounting of disclosures of protected health information. 7. The right to obtain a paper copy of the Privacy Notice fro the covered entity upon request. 8. The right to file a complaint if you believe your privacy rights have been violated. You will not be penalized for filing a complaint. 9. The right to receive timely notification of any breach of your unsecured protected health information.
Neuropsychology Associates of Fairfax may us or disclose your health information for any purpose based on a signed, written authorization you provide us. Your signed written authorization is always required to disclose your psychotherapy notes if they exist. If we were to disclose your health information for marketing purposes we would require your signed written authorization. In all other cases, we will not use or make a disclosure of your health information without your signed, written authorization, unless the use or disclosure falls under one of the the exceptions described in this Notice. When we receive your signed written authorization we will review the authorization to determine if it is valid, and then disclose your health information as requested by you in authorization. You may revoke this written authorization at any time.
Forms to exercise your rights can be obtained from the Office Manager or our HIPAA Compliance Officer.
Neuropsychology Associates of Fairfax is required by law to maintain the provacy of protected health information and to provide individuals with notice of its legal duties and privacy practices with respect to protected health information. Neuropsychology Associates of Fairfaxis required to abide by the terms of the Notice currently in effect.
Neuropsychology Associates of Fairfax reserves the right to change the terms of this Notice. The new Notice provisions will be effective for all protected health information that it maintains. Neuropsychology Associates of Fairfax will provide individuals or patients with a revised Notice by posting new regulations in the office.
It is presumed that any acquisition, access, use or disclosure of PHI not permitted under HIPAA regulations is a breach. We are required to complete a risk assessment, and if necessary, inform HHS and take any other steps required by law. You will be notified of the situation and any steps you should take to protect yourself against harm due to the breach.
Neuropsychology Associates of Fairfax, 3020 Hamaker Court, Suite 103, Fairfax, VA 22031, (703) 876-0966
If you are not satisfied with the manner in which this office handles a complain, you may submit a formal complaint to : OCRMail@hhs.gov or call 800-368-1019.
I hereby acknowledge that I have been made aware of the Neuropsychology Associates of Fairfax Notice of Privacy Practices, that a copy is available in the patient waiting room, on the www.neuropsychologyfairfax.com website, or available upon request in the office.
I AUTHORIZE THE WRITTEN AND VERBAL RELEASE OF PERSONAL HEALTH INFORMATION RELEVANT TO MY CARE TO THE FOLLOWING INDIVIDUALS. I UNDERSTAND THAT THIS CONSENT WILL REMAIN IN EFFECT UNTIL REVOKED IN WRITING.
AUTHORIZATION TO RELEASE RECORDS
I hereby authorize Neuropsychology Associates of Fairfax to release my neuropsychological report to the following recipients:
TELEHEALTH CONSENT FORM
(YOU MAY SKIP THIS FORM IF YOU ARE SCHEDULED FOR AN IN-OFFICE VISIT)
Neuropsychology Associates of Fairfax (NAF) is offering neuropsychological evaluation services using telehealth and videoconferencing. We are implementing telehealth to facilitate the provision of our services in the safest possible way during the COVID-19 pandemic. Making use of videoconferencing is possible because of changes in billing where Medicare and other insurance carriers are now reimbursing the use of telehealth methods in the provision of neuropsychological assessments and due to the accumulation of research supporting the use of neuropsychological services offered remotely.
Providing for assessments using telehealth means that the patient and examiner will be at different locations and that they will be connected with each other using videoconferencing. Then initial interview will be conducted remotely using videoconferencing and other family members may be present with the patient to provide information. This is similar to in-person visits where friends or family members may accompany the patient to provide information. Once the evaluation and testing starts, no family member can be present. The patient wil be informed if any additional NAF staff member is present other than the examiner. The patient may request at any time for the additional NAF staff person to not be present during the evaluation. It is important that the patient be in a private, comfortable, quiet, and well-lit room with no distractions. The patient should also have a desk or table where he or she can write.
The examiner doing the testing will ask the patient to perform certain tasks that require different cognitive skills. The examiner may also show the patient different pictures that will be presented on the patient's video monitor. If the picture does not look clear, or if it is hard to understand the examiner, the patient should tell the examiner immediately. Neither patients not individuals who may be located at the same place as the patient are allowed to copy or record any portion of the examination. This includes taking screen shots of test materials. Copying test materials violates copyright laws and is illegal. Any productions made by the patient (things written or drawn) cannot be kept or copied. Productions must be sent back to NAF or destroyed. These productions cannot be shared with any other individual and may also constitute a copyright violation in that they may be drawings of protected material. Protecting test materials is required by law and is necessary to ensure their continued validity.
NAF will not be recording any part of the telecommunications. However, there will be instances where the doctor, examiner or administrative staff will need to take a screen shot (still picture). This will include (but not limited to) taking a still shot of the patient to verify against identification to validate identity; taking a still shot of pages the patient has written on as part of their testing materials.
Similar to making an in-office visit, patients will be asked to provide personal identification to NAF staff and to complete forms related to obtaining background information and billing. Other administrative forms must be completed such as releases of information that allow us to send the report of your examination to referring physicians and others who you designate. Separate releases of information forms also allow us to obtain information from referring health providers. You will be given information regarding regulations and your rights under the Health Insurance Portability and Accountability Act (HIPAA).
To accomplish the in-home assessment via telehealth in a manner that meets HIPAA standards, NAF will use HIPAA compliant technology making use of end-to-end encryption. NAF cannot guarantee internet transmission against all threats. NAF will ensure our approach to remote evaluations meets required standards. The examination will not be recorded without your separate written permission. All documents and test results produced by the assessment will be held securely by NAF in the same manner as if the evaluation was taking place in-person.
NAF views telehealth as a method to safely and conveniently provide neuropsychological evaluations. Research data indicates that examinations can be done remotely obtaining accurate data that can benefit patients and their referring healthcare providers. At this point in time not every test available for in-office administration is available via telehealth. We also believe it is important to reduce the time of testing when it is done remotely and provided in-home. Patients may elect not to engage in evaluations via telehealth and instead request an in-office appointment as these appointments become available. We may also schedule an in-office appointment as a follow-up to an in-home telehealth visit.
The ability to carry out online assessment depends on having a reliable internet connection with transmission adequate for conversation and test administration. If a patient does not have a workable internet connection, we will schedule an in-office visit. If the internet connection is disrupted or degrades, we will attempt to re-establish the connection. If re-establishing the connection does not work, we will reschedule the telehealth appointment at a different time or schedule an in-office visit as in-office visits become available.
I have read the above information and agree to all indicated stipulations. I have been given time to ask questions. I agree to undergoing a remote evaluation using video conferencing.