Aspire Health Services, LLC
4 Ephriam Rd Clarksburg, NJ 08510 (609) 208-2044 office (609)
208-2045 fax

NEW JERSEY NOTICE FORM

Notice of Mental Health Professionals’ 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:
ÿ "PHI" refers to information in your health record that could identify you.
ÿ "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 mental health professional.
- Payment is when I obtain reimbursement for your healthcare. 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.
ÿ "Use" applies only to activities within my office, such as sharing,
employing, applying, utilizing, examining, and analyzing information that
identifies you.
ÿ "Disclosure" applies to activities outside of my office, such as releasing,
transferring, or providing access to information about you to other parties.

II. Uses and Disclosures 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 from you 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:

ÿ 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.

ÿ 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.

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

ÿ 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.

ÿ Serious Threat 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.

ÿ 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
participant in the worker’s compensation case, a reinsurer, 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 Mental Health Professional’s Duties

Patient’s Rights:

ÿ 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.

ÿ 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.)

ÿ 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 cases, you may have this decision reviewed. On your request, I will
discuss with you the details of the request and denial process.

ÿ 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.

ÿ 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 the accounting process.

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

Mental Health Professionals’ Duties:

ÿ I am required by law to maintain the privacy of PHI and to provide you with
a notice of my legal duties and privacy practices with respect to PHI.
ÿ I reserve the right to change the privacy policies and practices described
in this notice. Unless I notify you of such changes, however, I am required
to abide by the terms currently in effect.
ÿ If I revise my policies and procedures, I will provide individuals with a
revised notice.

V. Complaints

If you are concerned that I have violated your privacy rights, or you
disagree with a decision I made about access to your records, you may contact
Ellen Deckoff at 609-208-2044.

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

This notice will go into effect on April 5, 2003.