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» Provider Directory » Find a Therapist » New York » Lynbrook Therapists » Therapist Profile

 

Lois Plitt Warren, MPS, ATR-BC, LCAT

HIPPA Form

Lois Plitt Warren, MPS, ATR-BC, LCAT

45 North Station Plaza, Suite 202211 Broadway, Suite 207

Great Neck, New York 11021Lynbrook, NY 11563

516-967-7530

NOTICE OF PRIVACY PRACTICES:

As a result of the Health Insurance Portability and Accountability Act (HIPAA),

Enforced by the US Department of Health and Human Services Office of Civil Rights, the Office of the Inspector General, OSHA and HCFA, I am not permitted to release patient information except as stated in the Notice of Privacy Practices, the Artistic Release Consent, or in accordance with your wishes as stated below.

This waiver authorizes Lois Plitt Warren, MPS, ATR-BC, LCAT to send/give my clinical information as noted:

Leave a voice mail recording on my home phone.Yes __No__#_____________________________

Leave a voice mail recording & text on my cell phone. Yes _No__#___________________________

Leave a voice mail recording on my business phone. Yes __No__#___________________________

Leave a voice mail recording on the following phones: Yes__ #________________________________

__________________________________________________________________________________

Send an email to the following address(es) Yes__________________________________________________

_____________________________________________________________________________________

Information may be mailed to my home. Yes __No__

Permit the following individual(s) other than myself to pick up files or forms:

Name______________________________________ relationship_________________________________

Name______________________________________ relationship_________________________________

Speak to my insurance company representatives, my health care providers and education professionals. Yes __No__ Comments_______________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

_____________________________________________________________________________________

Both by law and the standards of my profession, I am required to keep appropriate treatment records. You are entitled to receive a summary of the records. Because these are professional records, they can be misinterpreted and/or misunderstood. If you wish to see this summary, I recommend that you review it in my presence so that we can discuss what it contains. You will be charged an appropriate fee for any preparation time, which is required to comply with any information request.

 

On this date __________________ I received and reviewed this Notice of Privacy Practices, which describes how my medical information may be used and disclosed and explains how I can gain access to this information.

I have had an opportunity to raise questions regarding this policy and all of my questions have been answered.

This will remain effective until such time as I notify Lois Plitt Warren, MPS, ATR-BC, LCAT in writing by certified mail.

________________________________________________________________

Print Client’s NameDate of birth

________________________________________________________________

Print Guardian’s name (if applicable) Signature of Client or Guardian

________________________________________________________________

Address

________________________________________________________________

Name of WitnessSignature of Witness


Lois Plitt Warren, MPS, ATR-BC, LCAT, Lynbrook

 Office Locations
Lynbrook, NY 11563
Great Neck, NY 11021

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Last Modified: 1/23/2019  


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