*This information is being disclosed under the authority, protection and provisions of applicable Federal law (including but not limited to HIPAA) and State statute and in compliance with New Jersey mental health regulations. This authorization is only valid for the information, individuals and organizations cited above. I consent for this office to try to obtain information to help me monitor paid services. The includes the ability to obtain information by telephone, on the internet, or by fax. These laws prohibit any further disclosure of this information, unless further disclosure is expressly permitted by written authorization by the person to whom it pertains or as otherwise permitted by regulation.

I understand that this release may or may not contain information pertaining to psychiatric treatment, medical treatment, alcohol or drug abuse treatment, and infectious diseases (including but not limited to such diseases as HIV, AIDS, Hepatitis, TB, Various Sexually Transmitted Diseases). I do expressly and voluntarily authorize the disclosure of the above-indicated information to the person(s) or entity(ies) as stated above. I also understand that this information may be released via the U.S. Postal Service, an overnight delivery service or by way of facsimile.

By signing below you are authorizing our office to obtain and/or distribute records as requested.

I irrevocably authorize and direct you, my attorney, to pay directly to Robert Pasahow, Ph.D., LLC any balance that I have outstanding to Robert Pasahow, Ph.D., LLC. This would relate to the above accident (s) or any other services related to the lawsuit that I have with the firm who is receiving this Lawyer Authorization and Lien Form. Money is owed for services related to the above identified accident or current lawsuit. The entire bill from Robert Pasahow, Ph.D., LLC is to be protected from the settlement of this case. Robert Pasahow, Ph.D., LLC will bill their regular fees. These fees are available upon request. A co-pay and full payment of fees when services rendered will not be necessary. Payment of fees at the end of the case is not limited to health insurance reimbursement schedules. I fully understand that I am directly and fully responsible to Robert Pasahow, Ph.D., LLC for all bills submitted for services rendered to me and/or my family. This irrevocable Authorization and Lien Agreement is made solely for Robert Pasahow, Ph.D., LLC’s protection in consideration of Robert Pasahow, Ph.D., LLC awaiting payment and not directly billing me as services are rendered. Payment will be due at the time of settlement.

 

I hereby acknowledge that this agreement to not rescind this Lawyer Authorization and Lien Form, given that Robert Pasahow, Ph.D., LLC agreed to treat me while waiting for the settlement of the pain and suffering lawsuit before receiving payment. I also agree that this document is irrevocable and that I will not rescind this Lawyer Authorization and Lien Form. I may choose to change lawyers. I agree not to rescind this Lawyer Authorization and Lien Form even if my attorney changes law firms and my case is to be settled by the new law firm or the current law firm for services rendered related to the accident listed above. I agree never to rescind this document. As such, my signing of this form binds me to this agreement that any future attempt to rescind this agreement will not be honored by the attorney. The signing of this form is my agreement to not have the new attorney declare this signed Lawyer Authorization and Lien form null and void. I hereby instruct that in the event that another attorney is substituted in this matter, the new attorney honor this Lawyer Authorization and Lien as inherent to the settlement and enforceable upon the case. In the event I have more than one accident where I am awaiting settlement for pain and suffering, I authorize my attorney (s), to pay the outstanding balance I have with Robert Pasahow, Ph.D., LLC even if the settlement of monies is from a case other than the case of the accident identified above in this form

As medical provider I agree to attempt to reasonably comply with the PIP carrier’s decision point review/pre-certification plan and to hold the patient harmless if I fail to comply with same, in consideration for the carrier’s consent to this assignment.

In the event the insurance carrier responsible for making medical payments in this matter does not accept my assignment, or my assignment is challenged or deemed invalid, I execute this limited/special power of attorney and appoint and authorize your collection attorney as my agent and attorney to collect payment for your medical services directly against the carrier in this case in my name including filing an arbitration demand or lawsuit. I specifically authorize that attorney to file directly against the carrier in my name or in your name as a medical provider rendering services to me and designate your collection attorney as my attorney in fact. I further grant limited power of attorney to you as my medical provider to receive and collect directly from the insurance carrier money due you for services rendered to me in this matter, and hereby instruct the insurance carrier to pay you directly any monies due you for medical services you rendered to me.

I authorize you and or your attorney to obtain medical information regarding my physical condition from any insurance carrier and any other health care provider, including hospital, diagnostic centers, etc., and I specifically authorize such health care provider(s) and insurance carrier to release all such information to you about me, including medical reports, X-ray reports, narrative reports and any other report or information regarding my physical condition.

I hereby authorize my insurance carrier to pay by check made out and mailed DIRECTLY to:

 

Robert Pasahow, Ph.D., LLC

600 New Road

Northfield, NJ 08225

 

for psychological, diagnostic, and psychotherapeutic expense benefits allowable, and otherwise payable to me under any current insurance policy, as payment toward the total charges for Professional Services Rendered.

In addition, I agree to pay, in a timely manner, any and all balances of said Professional Services Rendered over and above this insurance payment.

Finally, I authorize the release of any medical records and information deemed necessary in order to process such insurance claims and get reauthorization for further treatment.

Should payment by my insurance carrier require any endorsement, I authorize Robert Pasahow, Ph.D., LLC to endorse and cash any check received as payment for their services on my behalf.

I authorize my psychotherapist, Robert Pasahow, Ph.D. to send a brief letter to my primary physician.

By signing this notice below, you are acknowledging you are in receipt of notice that Robert Pasahow, Ph.D., LLC is not a provider for New Jersey Medicaid or any Medicaid products: Horizon NJ Family Care, Amerigroup, United Healthcare Community Plan. We recommend that you check your insurance if you are not sure.

I, the undersigned, acknowledge that if there is any balance due to deductible or coinsurance that
I am responsible for payment.

Thank you.

Notice of Psychologists’ and Psychotherapists’ Policies and Practices to Protect the Privacy of Your Health Information

THIS NOTICE DESCRIBES HOW PSYCHOLOGICAL AND MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY

I. Uses and Disclosures for Treatment Payment and Health Care Operations

I may use or disclose your protected health information (PHI) for treatment, payment and health care operations purposes with your consent. To help clarify these terms, here are some definitions.

• “PHI” refers to information in your health record that could identify you.

• “Treatment, Payment and Health Care Operations”

-Treatment is when I provide, coordinate, or manage your health care and other services related to your health care. An example of treatment would be when I consult with another health care provider, such as your family physician or another psychologist.

-Payment is when I obtain reimbursement for your health care. Examples of payment are when I disclose your PHI to your health insurer to obtain reimbursement for your health care or to determine eligibility or coverage.

-Health Care Operations are activities that relate to the performance and operation of my practice. Examples of health care operations are quality assessment and improvement activities, business-related matters such as audits and administrative services, and case management and care coordination.

• “Use” applies only to activities within my (office, clinic, practice group, etc.) such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.

• “Disclosure” applies to activities outside of my (office, clinic, practice group, etc.) such as releasing, transferring, or providing access to information about you to other parties

II. Uses and Disclosure Requiring Authorization

I may use or disclose PHI for purposes outside of treatment, payment, and health care operations when your appropriate authorization is obtained. An “authorization” is written permission above and beyond the general consent that permits only specific disclosures. In those instances when I am asked for information for purposes outside of treatment, payment, and health care operations, I will obtain an authorization before releasing this information. I will also need to obtain an authorization before releasing your psychotherapy notes. “Psychotherapy notes” are notes I have made about our conversation during a private, group, joint, or family counseling session, which I have kept separate from the rest of your medical record. These notes are given a greater degree of protection than PHI.

You may revoke all such authorizations (of PHI or psychotherapy notes) at any time, provided each revocation is in writing. You may not revoke an authorization to the extent that (1) I have relied on that authorization, or (2) if the authorization was obtained as a condition of obtaining insurance coverage, and the law provides the insurer the right to contest the claim under the policy.

III. Uses and Disclosures with Neither Consent nor Authorization

I may use or disclose PHI without your consent or authorization in the following circumstances:

• Child Abuse: If I have reasonable cause to believe that a child has been subject to abuse, I must report this immediately to the New Jersey Division of Youth and Family Services.

• Adult and Domestic Abuse: If I reasonably believe that a vulnerable adult is the subject of abuse, neglect, or exploitation, I may report the information to the county adult protective services provider.

• Health Oversight: If the New Jersey State Board of Psychological Examiners issues a subpoena, I may be compelled to testify before the Board and produce your relevant records and papers.

• Judicial or Administrative Proceedings: If you are involved in a court proceeding and a request is made for information about the professional services that I have provided you and/or the records thereof, such information is privileged under State law, and I must not release this information without written authorization from you or your legally appointed representative, or a court order. This privilege does not apply when you are being evaluated for a third party or where the evaluation is court ordered. I must inform you in advance if this is the case.

• Serious Threats to Health or Safety: If you communicate to me a threat of imminent serious physical violence against a readily identifiable victim or yourself and I believe you intend to carry out that threat, I must take steps to warn and protect. I also must take such steps if I believe you intend to carry out such violence, even if you have not made a specific verbal threat. The steps I take to warn and protect may include arranging for you to be admitted to a psychiatric unit of a hospital or other health care facility, advising the police of your threat and the identity of the intended victim, warning the intended victim or his or her parents if the intended victim is under 18, and warning your parents if you are under 18.

• Worker’s Compensation: If you file a Worker’s Compensation claim, I may be required to release relevant information from your mental health records to a participate in the Worker’s Compensation case, a re-insurer, the health care provider, medical and non-medical experts in connection with the case, the Division of Worker’s Compensation, or the Compensation Rating and Inspection Bureau.

IV. Patient’s Rights and Psychologist’s Duties

Patient’s Rights:

• Right to Request Restrictions: You have the right to request restrictions on certain uses and disclosures of protected health information about you. However, I am not required to agree to a restriction you request.

• Right to Receive Confidential Communications by Alternative Means and at Alternative Locations: You have the right to request and receive confidential communications of PHI by Alternative means and at alternative locations. (For example, you may not want a family member to know that you are seeing me. Upon your request, I will send your bills to another address.)

• Right to Inspect and Copy: You have the right to inspect or obtain a copy (or both) of PHI and psychotherapy notes in my mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record. I may deny your access to PHI under certain circumstances, but in some case, you may have this decision reviewed. On your requests, I will discuss with you the details of the request and denial process.

• Right to Amend: You have the right to request an amendment of PHI for as long as the PHI is maintained in the record. I may deny your request. On your request, I will discuss with you the details of the amendment process.

• Right to an Accounting: You generally have the right to receive an accounting of disclosures of PHI for which you have neither provided consent nor authorization (as described in Section III of this Notice). On your request, I will discuss with you the details of this accounting process.

• Right to a Paper Copy: You have the right to obtain a paper copy of the notices from me upon request, even if you have agreed to receive the notice electronically.

 

Psychologist’s Duties:

• Robert Pasahow phd LLC are requested by law to maintain the privacy of PHI and to provide you with a notice of our legal duties and privacy practices with respect to PHI.

• Robert Pasahow phd LLC reserve the right to change the privacy policies and practices described in this notice. Unless Robert Pasahow phd LLC notify you of such changes, however, we are required to abide by the terms currently in effect.

• If Robert Pasahow phd LLC revise our policies and procedures, you will be informed in writing by mail.

V. Complaints

If you are concerned that Robert Pasahow phd LLC have violated your privacy rights, or you disagree with a decision Robert Pasahow phd LLC have made about access to your records, you may contact Robert J. Pasahow, PhD at (609) 641-2500.

You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services. The person listed above can provide you with the appropriate address upon request.

VI. Effective Date, Restrictions, and Changes to Private Policy

This notice will go into effect on April 14, 2003.

Robert Pasahow, Ph.D., LLC  reserve the right to change the terms of this notice and to make the new notice provisions effective for all PHI that Robert Pasahow, Ph.D., LLC maintain. Robert Pasahow, Ph.D., LLC will provide you with a revised notice by mail.

This form when completed and signed by you, authorizes me to release protected information from your clinical record to the person you designate.

I authorize Robert Pasahow, Ph.D., LLC and/or his or her administrative and clinical staff to release contents of my chart of information necessary for billing, collections and as I may otherwise specify. I understand that my insurance company requests specific information.

This information should only be released to: Insurance Company and Managed Care Company

It is at my request that I am asking Robert Pasahow, Ph.D., LLC to release this information.

This authorization shall remain in effect for two years. I realize that I can request in writing that the Release be shortened.

You have the right to revoke this authorization, in writing, at any time by sending such written notification to my office address. However, your revocation will not be effective to the extent that I have taken action in reliance on the authorization or if this authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim.

I understand that my psychologist or psychotherapist generally may not condition psychotherapeutic services upon my signing an authorization unless the psychological services are provided to me in which payment for such services comes from the third party insurance company.

I understand that information used or disclosed pursuant to the authorization may be subject to re-disclosure by the recipient of your information and no longer protected by the HIPAA Privacy Rule.

If the authorization is signed by a personal representative of the patient, a description of such representative’s authority to act for the patient must be provided.

Documents:

Click here to download Receipt of Privacy Notice

I acknowledge that I received the Notice of Privacy Practice for Robert Pasahow, Ph.D., LLC

Please be aware that I schedule one person at a time. Over the years patients have expressed their frustration about having to wait long periods of time for their doctor to see them. Thus, I’ve had a policy for a number of years of not scheduling multiple people at a certain time slot. The time slot you will be given leads to a session beginning at a predictable time and ending at a predictable time. If you are seeing other doctors, sometimes it is best to make your appointments with us first as my office can reliably get you out at a time that you will know ahead. For official business issues, it is best to call our number at Extension 113 or 130. You agree, in order for us to service your account or to collect monies you may owe, Robert Pasahow phd LLC in Psychotherapy and/or our agents may contact you by telephone at any telephone number associated with your account, including wireless telephone numbers, which could result in charges to you. We may also contact you by sending text messages or emails, using any email address you provide to use. Methods of contact may include using pre-recorded/artificial voice messages and/or use of automatic dialing device, as applicable. Please give the office as much notice as possible when you cannot make an appointment. We do have a 24 hour answering service. You can call during non-work office hours with regard to any appointment and leave a message at Extension 110.