PROFESSIONAL
DISCLOSURE STATEMENT
DIANE S. FEINBERG, M.ED.
April 2004
I arm required by law to protect the privacy of medical information
about you and that identifies you [information I refer to in
this notice as “Protected Health Information”]. This
medical information may be information about health care I provide
to you or payment of health care provided to you. It may also
be information about your past, present or future medical condition.
I am required to provide you with this notice regarding my policies
and procedures regarding your Protected Health Information and
to abide by the terms of this notice, as it may be updated from
time to time.
I am permitted to make certain types of uses and disclosure under
applicable law for treatment, payment and health care operations
purposes
TREATMENT AND DIAGNOSIS:
I may use and disclose medical information about you to provide
health care treatment to you. In other words, I may use and disclose
medical information about you to provide, coordinate or manage
your health care and related services. This may include communicating
with other health care providers regarding your treatment and coordinating
and managing your health care with others.
EXAMPLE: You may contact your health plan seeking services. An
intake specialist will contact me for the purposes of referring
you to this counseling center. The intake specialist will share
health information about you pertinent to this referral.
A diagnosis must be made if the client desires reimbursement from
insurance or if the client’s care must be coordinated with
other health care providers. Once the diagnosis is given, it becomes
a part of the client’s records and the same privacy/confidentiality
rulings and exceptions apply
PAYMENT:
I may use and disclose medical information about you to obtain
payment for health care services that you received. This means
that I may use medical information about you to arrange for payment
[such as prepared bills and managing accounts]. I may also disclose
medical information about you to others [such as insurers, collection
agencies and consumer reporting agencies]. In some instances, I
may disclose medical information about you to an insurance plan
before you receive certain health care services, because, for example,
I may want to know whether the insurance plan will pay for a particular
service.
EXAMPLE: While receiving services at my center, I will use your
health information to verify health insurance coverage [private,
Medicaid, Medicare, etc.]. The health information will be used
to receive payment for services.
HEALTH CARE OPERATIONS:
For health care operations purposes, I may use and disclose medical
information in a number of ways, including for quality assessment
and improvement, case consultation, provider review, and training
of other professionals. Your information, for example, could be
used to assist in the evaluation of the quality of health care
you were provided.
EXAMPLE: You could be determined to have an anger management problem.
I may design an educational program, using your health care information
to help consumers recognize their anger triggers and develop improved
strategies for dealing with their anger. [ The education program
would not identify any specific consumers without their permission.]
EXAMPLE: As a part of a periodic audit, a health care plan could
require that copies of your record be sent to verify the quality
of the service that you were provided, and the center could be
asked to provide justification for a particular course of treatment.
In addition, there may be periodic site visits by your health plan
provider
to review files for quality assurance purposes.
REQUIRED BY LAW:
I will use and disclose medical information about you whenever
I am required by law to do so. There are many state and federal
laws that require me to use and disclose medical information. I
will comply with those laws in areas as:
THREAT TO HEALTH AND SAFETY:
I will use or disclose medical information about you if I believe
it is necessary to prevent or lessen a serious threat to health
or safety.
PUBLIC HEALTH ACTIVITIES:
I may use or disclose medical information about you for such public
health activities as investigating diseases and reporting child
abuse and neglect. For example, if you have been exposed to a communicable
disease, such as SARS, I may report it to the state and take other
actions to prevent the spread of the disease.
ABUSE, NEGLECT OR DOMESTIC VIOLENCE:
I may disclose medical information about you to a government
authority [such as the Department of Social Services] if you are
an adult and I reasonably believe that you may be a victim of abuse,
neglect or domestic violence, or if I believe that you are abusing
a child or another adult.
HEALTH OVERSIGHT ACTIVITIES:
I may disclose medical information about you to an agency responsible
for overseeing the health care system or certain governmental programs.
For example, a government agency may request information from me
while they are investigating possible insurance fraud.
COURT PROCEEDINGS:
I may disclose medical information about you to a court or an
officer of the court [such as an attorney]. For example, I would
disclose medical information about you to a court if a judge orders
me to do so.
LAW ENFORCEMENT:
I may disclose medical information about you to a law enforcement
official for specific law enforcement purposes. For example, I
may disclose medical information about you to a police officer
if the officer needs the information to help find or identify a
missing person.
WORKER’S COMPENSATION:
I may disclose medical information about you in order to comply
with worker’s compensation laws.
RESEARCH ORGANIZATIONS:
I may use or disclose medical information about you to research
organizations if the organization has satisfied certain conditions
about protecting the privacy of medical information.
CERTAIN GOVERNMENTAL FUNCTIONS:
I may use or disclose medical information about you for such governmental
functions, including, but not limited to military and veterans’ activities
and national security and intelligence activities. I may also use
or disclose medical information about you to a correctional institution
in some circumstances.
I may use your Protected Health Information for sending out appointment
reminders, in order to reach you, should there be problems with
contacting you by information in my files, or in making recommendations
for other treatment alternatives.
PERSONS INVOLVED IN YOUR CARE:
I may disclose medical information about you to a relative, close
personal friend or any other person you identify, if that person
is involved in your care and the information is relevant to your
care. If the patient is
a minor, I may disclose medical information about the minor to
a parent, guardian, or other person responsible for the minor,
except in limited circumstances. You have a right to influence
how your Protected Health Information is disclosed to family members,
friends or other persons involved in your care. However, requests from you to restrict disclosure of your Protected
Health Information to persons involved in your care or payment
of your services may not be honored.
AUTHORIZATION:
Other than the uses and disclosures described above, I will not
use or disclose medical information about you without the “authorization” -or
signed permission- of you, or your personal representative. In
some instances, I may wish to use or disclose medical information
about you and I may contact you to ask you to sign an authorization
form. In other instances, you may contact me to ask me to disclose
medical information and I will ask you to sign an authorization
form.
If you sign a written authorization, allowing me to disclose medical
information about you, you may later revoke [or cancel] your authorization
in writing [except In very limited circumstances related to obtaining
insurance coverage]. If you would like to revoke your authorization,
you may write me a letter revoking your authorization. If you revoke
your authorization, I will follow your instructions, except to
the extent that I have already relied upon your authorization and
taken some action.
RIGHTS IN RESPECT TO YOUR PROTECTED HEALTH INFORMATION:
You have several rights with respect to your Protected Health
Information. This section will briefly mention each of these rights.
If you would like to know more about your rights, please contact
me.
RIGHT TO A COPY OF THIS NOTICE:
You have a right to have a paper copy of my Privacy Notice at
any time. In addition, a copy of this Notice will always be posted
in my waiting area. If you would like to have a copy of my Privacy
Notice, please contact my Privacy Officer.
RIGHT TO ACCESS TO INSPECT AND COPY:
You have a right to inspect [which means to see or review] and
receive a copy of medical information about you that I maintain
in certain groups of records. If you would like to inspect or receive
a copy of medical information about you, you must provide me with
a request in writing.
I may deny your request in certain circumstances. If I deny your
request, I will explain my reason for doing so in writing.
If you would like a copy of the information, I will charge you
a fee to cover costs of copy.
Diane S. Feinberg, M.Ed. charges a fee of $3.00 for the first three
pages and 25 cents for any copies after the three pages.
It may make more sense , in certain instances to provide you with
a summary or explanation of the information, especially if your
record is lengthy. Contact my Privacy Officer for more information
on these services and any other possible additional fees.
RIGHT TO HAVE MEDICAL INFORMATION AMENDED:
You have a right to have me amend [which means correct or supplement]
medical information about you that I maintain in certain groups
of records. If you believe that I have information that is either
inaccurate
or incomplete, I may amend the information to indicate the problem
and notify others who have copies of the inaccurate or incomplete
information, you must provide me with a request in writing and
explain why you would like me to amend the information.
I may deny your request in certain circumstances. If I deny your
request, I will explain my reasoning for doing so in writing. You
will have the opportunity to send me a statement explaining why
you disagree with
my decision to deny your amendment request and I will share your
statement whenever I disclose the information in the future.
RIGHT TO HAVE AN ACCOUNTING OF DISCLOSURES I HAVE MADE:
You have a right to receive an accounting [which means detailed
listing] of disclosures that I have made for the previous six [6]
years. If you would like to receive an accounting, you may send
me a letter requesting an accounting or contact my privacy officer.
The accounting will not include several types of disclosures,
such as disclosures for treatment, payment, or health care operations.
It will also not include disclosures made prior to April 14, 2003.
If you request an accounting more than every twelve [12] months,
I will charge you a $25.00 fee to cover costs of preparing the
accounting.
RIGHT TO REQUEST RESTRICTIONS ON USES AND DISCLOSURES:
You have the right to request that I limit the use and disclosure
of medical information about you for treatment, payment and health
care operations. However, I am not required to agree with your
request.
If I do not agree to your request, I must follow your restrictions
[except if the information is necessary for emergency treatment].
You may cancel the restrictions at any time as long as I notify
you of the cancellation and continue to apply the restriction to
information collected before cancellation.
RIGHT TO REQUEST AN ALTERNATIVE METHOD OF CONTACT:
You have a right to be contacted at a different location or by
a different method. For example, you may prefer to have all written
information mailed to your work address rather than your home address.
I will agree to any reasonable request for alternative methods
of contact. If you would like an alternative method of contact,
you must provide me with a request in writing, or let me know at
the time of the original assessment or first meeting.
With regard to certain aspects of this Privacy Notice, North Carolina
state laws, as well as standards for Licensed Professional Counselors
ethics may provide you with even more protection than HIPAA [the
federal law with regards to privacy]. I will follow the requirements
of NC state laws, as well as the Licensed Professional Counselor’s
code of ethics.
If you believe that your privacy rights have been violated or
if you are dissatisfied with my privacy policy or procedures, you
may file a complaint either with me or the federal government.
I will not take any action against you or change my treatment of
you in any way if you file a complaint.
To file a complaint with Diane S. Feinberg, Please write:
Diane S. Feinberg
#59 Covered Bridge Drive
Flat Rock, North Carolina 28731
To file a complaint with the North Carolina Board of Licensed
Professional Counselors, you may send your complaint to the following
address:
NCBLPC
P.O. Box 1369
Garner, N.C. 27529-1369
To file a complaint with the federal government, you may send
your complaint to the following address:
Office for Civil Rights
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F HHH Building
Washington, D.C. 20201
In some instances, it may be appropriate to make complaints directly
to your health care plan, in which case you would contact the customer
relations number on the back of your insurance or health care plan
card.
DIANE S. FEINBERG, M.ED.
Counseling and Human Services Boston University, 1974
New Mexico LPC :#0065162
New Mexico LPCC: #0071681
Ms. Feinberg is currently pursuing licensure as a Licensed Professional
Counselor in North Carolina.
She has 28 years of counseling experience.
CLIENTELE SERVED:
- Adoptive families and Adoptees with emphasis on attachment
and bonding.
- Children, Adolescents and Teens with emphasis on attachment
and bonding
- Parents [education]
- Couples- premarital, marital, divorce and other
Substance Abusers in recovery
- Family members of Substance Abusers and Codependents
- Those who are depressed, in life transitions, those seeking
personal and spiritual growth
- Groups for those seeking personal and spiritual growth,
enhancing relationships with others, Codependents,
or those in life
transitions.
- Stress management
THEORETICAL ORIENTATION:
My orientation is a holistic one, taking into account the whole
person, his or her family background, present family and environment.
Though I believe in the importance in the family of origins rules,
roles and relationships, I try to bring that material into the
present context of the client by offering experiential vignettes.
If working with families, I use family systems models and Direct
Synchronous Bonding and Attachment models.
I might have clients role play, speak with an empty chair, or
I might use energetic exercises with a client with depression,
in addition to Cognitive Behavior Therapy, and reframing. I am
a great believer in assigning homework to help clients utilize
what is transpiring in the therapy sessions while they are at home.
In Attachment Therapy intensives, I model desirable parenting
techniques and help parents to make appropriate, on the spot interventions,
in addition to the structured Family Therapy sessions.
INFORMATION REGARDING FEES:
My usual policy is to collect the full fee up front, at the beginning
of each session. If you are claiming insurance benefits, it is
still customary to collect the full fee in advance and to give
you a billing statement to assist you in filing for insurance reimbursements
yourself. There may be some exceptions , depending on the limitations
and expectations of your insurance policy or Managed Care provider.
If you are a Managed Care Client, your co-payment is due at the
beginning of each therapy session.
Missed or canceled appointments will still be charged unless 24
hours advance notice is given.
FEES:
Payment may be made by personal check, cash, money order or bank
check.
Fifty minute office visit: $90.00
One and a half hour family intake session: $185.00
[Includes obtaining and reading histories of child and family members]
Attachment Therapy Intensives:
Local area, 24 to 30 hours, from $2400.00
Distant areas and Out of State, begin ant $4,050., [thirty hours
billed at $135.00 per hour, not including travel, room and board
expenses].
All Intensives include a written aftercare plan, devised together
with the family, for family members to implement.
Each Distant Intensive, in addition to an after care plan, includes
two- fifty minute phone sessions within the three months following
the Intensive.
One and one half hour Direct Synchronous Bonding session [Attachment
and Bonding Therapy]
In office: $135.00
Three hour Direct Synchronous Bonding session: $270.00
Groups: $30.00 per person per group session.
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