Intake Packet Step 1 of 13 7% All form data is encrypted and submitted securely over an SSL (HTTPS) connection. Please check your browser’s URL bar for the appearance of “https” or look for the “lock” icon for confirmation. Fields marked with an asterisk (*) are required. This form works best using Chrome browser. DISCLAIMER Before you complete this form, please click here to read SPOP’s policy regarding website privacy. We encourage you to use a private computer and a secure (private) internet connection to complete this form. If you are using a public or shared computer, please be sure to log out when you are finished. IMPORTANT: This form is not complete until you hit submit at the end.Welcome to SPOP! Client Name(Required) First Last Date of Birth(Required) Month Day Year Founded in 1979, SPOP is dedicated to enhancing the quality of life of older adults and to fostering their independent living through the delivery of comprehensive mental health and supportive services, advocacy and education. SPOP’s values are: A Commitment to High-Quality Services Integrity and Respect Person-Focused Treatment Inclusivity and Acceptance We look forward to working with you on your treatment goals. All of our clinicians practice affirming care and are experienced in working with older adults of diverse backgrounds, and we offer services in multiple languages. Each client is assigned to a therapist based on availability and clinical fit. While we can take into consideration a client’s request or preferences, we are unable to guarantee matches to specific types of providers. We thank you for your flexibility and understandingIntake Acknowledgement – Welcome(Required) I have received and read the SPOP Welcome LetterI acknowledge receiving and reviewing the SPOP Welcoming Letter Missed Appointment Policy In order for SPOP to provide the highest quality of care, clients are required to attend sessions regularly. Therefore, SPOP has a strictly enforced Missed Appointment Policy. If you are unable to keep a scheduled appointment, you are required to call the clinic (212.787.7120 ext. 500/536) at least 24 hours in advance of your scheduled appointment, at which time we will work with you to reschedule as soon as possible. If two appointments are missed – with or without 24 hours advance notice – this will flag a review of your attendance and may result in termination of treatment. This Missed Appointment Policy is in effect immediately and applies as soon as you begin the intake process with us. If any appointment is missed – either with Case Opener or Psychiatrist/Nurse Practitioner – during your intake process, your case may not be opened. Please keep us informed of any potential scheduling conflicts as far in advance as possible. Given advance notice, we will make every effort to help you attend sessions regularly. Thank you for your cooperation. Intake Acknowledgement – Missed Appointment Policy(Required) I have received and read the SPOP Missed Appointment PolicyI acknowledge receiving and reviewing the Missed Appointment PolicyIMPORTANT: This form is not complete until you hit submit at the end. Payment for Services To provide you with the best possible care, we charge fees for our services. Clients with insurance are responsible only for deductibles and co-payments, if applicable. Co-payments are due at the time of service; deductibles will be billed at a later date. If you do not have insurance or if your insurance does not cover SPOP’s services, you will be responsible for your fee at the time of service. Fees and payment arrangements vary according to the services provided and the provisions of your insurance plan. Clients with supplemental insurance generally have no co-payments for their SPOP services, depending on the plan provisions. Clients with Medicaid have no co-payment. All clients who are able to pay are expected to do so as a condition of continued treatment. Change of Insurance If you are thinking of changing your insurance plan, it is very important that you discuss this decision with your SPOP treatment team before making any changes. Not all insurance carriers provide coverage for SPOP’s mental health services. If you change to an insurance company that does not cover our services, you will be responsible for fees for the services you receive through SPOP. To ensure continuation of treatment, SPOP staff will periodically require you to present your insurance information. Please be sure to have your insurance information available at every session. Billing Procedures Please be aware that, in accordance with Medicare billing regulations, some of your sessions with a SPOP social worker may be billed under the name of a supervising psychiatrist. The psychiatrist’s name will appear on the Medicare statements you receive. Your Medicare statement may also show a “patient responsibility” amount that differs from what SPOP charges. Be assured that you are responsible only for the co-payments that you pay to SPOP at the time of service. If you have questions about any of these policies, please speak with your social worker.Intake Acknowledgement – Payment for Services(Required) I have received and read the Payment for Services PolicyI acknowledge receiving and reviewing the SPOP Payment for ServicesIMPORTANT: This form is not complete until you hit submit at the end. Client Rights As a SPOP client, you have the right to: an individualized treatment plan a full explanation of the services you receive participate in treatment on a voluntary basis participate in developing your treatment poan raise questions regarding treatment privacy and confidentiality access to your records request restrictions on the use of your records request an amendment of your records an accounting of disclosures skilled and clinically appropriate treatment freedom from abuse and mistreatment non-discrimination respect for your cultural background language assistance file a grievance contact these agencies governmental agencies: New York State Office of Mental Health NY State Commission on Quality of Care for Persons with Disabilities Protection and Advocacy for Individuals with Mental Illness Mental Hygiene Legal Services NAMI–NYC Metro Office (National Alliance on Mental Illness) United States Department of Health and Human Services Office for Civil Rights Intake Acknowledgement – Client's Rights(Required) I have received and read Client RightsI acknowledge receiving and reviewing Client RightsIMPORTANT: This form is not complete until you hit submit at the end. SPOP Culture of Mutual Respect and Collaboration Guidelines SPOP works to create a culture of safety and mutual respect. All clients and guests of SPOP are expected to refrain from: Repeated calling or emailing beyond guidelines that have been established with your therapist Disruptive behavior including yelling at, insulting, cursing, or otherwise degrading SPOP staff or clients Use of derogatory language aimed at SPOP staff or clients’ culture, race, ethnicity, gender identity, sexual orientation, age, disability, religious or faith affiliation Engaging in acts of intimidation, including verbal or physical threats and and invading another person’s personal space Acting outside of these guidelines may result in discontinuation of services at SPOP and transition to an alternate provider.Intake Acknowledgement – Culture of Mutual Respect and Collaboration Guidelines(Required) I have received and read the Culture of Mutual Respect and Collaboration GuidelinesI acknowledge receiving and reviewing the Culture of Mutual Respect and Collaboration GuidelinesIMPORTANT: This form is not complete until you hit submit at the end. Grievance Policy Clients have the right to be informed of the Agency’s grievance policies and procedures. Clients have the right to initiate any question, complaint, or objection accordingly. Clients have access to their Program Director as first recourse in the grievance process. Clients have access to the agency’s Chief Program Officer and Chief Executive Officer as their second recourse in the grievance process. Clients may also contact the organizations listed below to initiate a grievance. Grievance Procedures If you are a client wishing to file a grievance, please contact the Senior Vice President (SVP) who oversees the program you attend. Grievances may be written or verbal; if the latter, please specify that you are lodging a grievance. You will receive an initial response within 5 business days, usually sooner. The SVP should be able to resolve the issue within 15 business days. If the SVP does not resolve the issue to your satisfaction within that time frame, or if the grievance is being filed against the SVP, please contact the Chief Program Officer (CPO) of SPOP. You will receive an initial response within 5 business days, usually sooner. The CPO should be able to resolve the issue within 15 business days. If the CPO does not resolve the issue to your satisfaction within that time frame, or if the grievance is being filed against the CPO, please contact the Chief Executive Officer (CEO) of SPOP. You will receive an initial response within 5 business days, usually sooner. The CEO should be able to resolve the issue within 15 business days. If the CEO does not resolve the issue to your satisfaction within that time frame, or if the grievance is being filed against the CEO, then you may contact any of the following agencies: New York State Office of Mental Health NY State Justice Center for the Protection of People with Special Needs Protection and Advocacy for Individuals with Mental Illness Mental Hygiene Legal Services NAMI–NYC Metro Office (National Alliance on Mental Illness) United States Department of Health and Human Services Office for Civil Rights Agencies Providing Oversight Of Mental Health Services New York State Office of Mental Health (OMH)44 Holland AvenueAlbany, NY 12229Customer Service:Toll-Free: 1-800-597-8481Toll-Free Spanish/Espanola: 1-800-210-6456Toll-Free TDD: 1-800-597-9810 NYS Justice Center for the Protection of People with Special Needs161 Delaware AvenueDelmar, NY 12054General Phone: 518-549-0200 Protection and Advocacy for Individuals with Mental IllnessNew York City Regional Office: New York Lawyers for the Public Interest 151 West 30th Street, 11th Floor New York, NY 10001-4007 212-244-4664 Mental Hygiene Legal ServicesFirst Judicial Department60 Madison Avenue – 2nd FloorNew York, NY 10010212-779-1734 NAMI–NYC Metro Office (National Alliance on Mental Illness)505 Eighth Avenue, Suite 1103New York, NY 10018212-684-3264 United States Department of Health and Human Services Office for Civil Rights(for complaints related to the HIPAA Privacy Rule)26 Federal PlazaSuite 3313New York, NY 10278212-264-3313TDD: 212-264-2355 Toll-Free: 800-368-101Intake Acknowledgement – Grievance Policy(Required) I have received and read the Grievance PolicyI acknowledge receiving and reviewing the Grievance PolicyIMPORTANT: This form is not complete until you hit submit at the end. Consent for Psychotherapeutic Services(Required)I hereby give consent for mental health treatment to be provided by Service Program for Older People (SPOP). I understand that I will receive regular psychotherapy sessions and may also be seen by members of a treatment team comprised of social worker(s), psychiatrist, psychiatric nurse practitioner, or peer, as indicated. I hereby give consent for mental health treatment to be provided by Service Program for Older People (SPOP). I understand that I will receive regular psychotherapy sessions and may also be seen by members of a treatment team comprised of social worker(s), psychiatrist, psychiatric nurse practitioner, or peer, as indicated.Signature(Required)I acknowledge I have received and read the following: Welcome to SPOP! Missed Appointment Policy Payment for Services Client Rights Grievance Policy & Procedures IMPORTANT: This form is not complete until you hit submit at the end. Information Release Consent – Medical professionals(Required)I hereby authorize the exchange of the following information: All medical information necessary to provide a complete assessment of my current condition and ongoing treatment. This may include, but is not limited to, all medical, surgical, psychiatric, and psychosocial information. between the Service Program for Older People, Inc. (SPOP) and the following individual or organization: (Include full name and telephone number) This release of information is for the purpose of: Assessment, treatment and coordination of my care. I understand that the information to be released remains confidential and may not be further disclosed to any parties other than those named above without my written consent. I agreeList(Required)Name of DoctorTelephone numberSpecialty; i.e. Primary care, Psychiatrist Add RemoveThis form is valid until:One year from the date I signed this form or this date: Information Release(Required)I understand that I have the right to cancel this consent in writing at any time, except to the extent that it has been acted upon. I agreeSignature(Required)Information Release Consent – Medical professionalsInformation Release Consent – Emergency Contact(Required)I hereby authorize the exchange of the following information: All medical information necessary to provide a complete assessment of my current condition and ongoing treatment. This may include, but is not limited to, all medical, surgical, psychiatric, and psychosocial information. between the Service Program for Older People, Inc. (SPOP) and the following individual or organization: (Include full name and telephone number) This release of information is for the purpose of: Assessment, treatment and coordination of my care. I understand that the information to be released remains confidential and may not be further disclosed to any parties other than those named above without my written consent. I agreeList(Required)NameTelephone numberRelationship Add RemoveThis form is valid for my emergency contact(s) until:One year from the date I signed this form or this date: Information Release(Required)I understand that I have the right to cancel this consent for my emergency contact(s) in writing at any time, except to the extent that it has been acted upon. I agreeSignature(Required)Information Release Consent – Emergency ContactIMPORTANT: This form is not complete until you hit submit at the end. Health ScreeningName of Primary Care Physician First Last Primary Care Physician PhonePrimary Care Physician Address Street Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Date of most recent physical exam Month Day Year Date of most recent dental appointment Month Day Year HeightWeight(in pounds)Medication allergies(Required)Please indicate “none” if there are no allergies. Add RemoveHistory(check all that apply) Heart Disease High Blood Pressure Diabetes Chronic Obstructive Lung Disease (COPD) Asthma Tuberculosis HIV/AIDS Kidney Disease Hepatitis Thyroid Problems Head injury Seizure Disorder/Epilepsy Stroke/TIAs Parkinson’s Disease Vision problems Hearing problems Arthritis Nervous/Muscular Disorder Stomach/Intestine/Colon Disease Cancer Dementia/Memory Problems Dental Problems Drug/Alcohol Problem Sexually transmitted Disease Insulin? Yes No Dialysis? Yes No Thyroid Problem? Overactive Underactive Please include any additional information here.(please specify)Do you smoke cigarettes?(Required) Yes No Number per dayDo you drink alcohol?(Required) Yes No Amount and frequencyDo you use other drugs?(Required) Yes No Amount and frequencyTypeHave you ever had major surgery?(Required) Yes No Please provide detailsPain AssessmentDo you currently have any physical pain?(Required) Yes No Location on body/commentsIf you have pain, is it adequately managed?(Required) Yes No Not applicable CommentsIf you have pain but it is well-managed, please indicate which supports and/or providers are helping with this:(If you need support to manage pain, please discuss onset, severity and pain management options with your Primary Care Provider.)AssistanceAssistive devices Cane Dentures Glasses Hearing aid Protective undergarments Respiratory aids Walker Wheelchair Other (please specify) OtherAmbulation Independent Uses assistive device History of falls Needs assistance (please specify) Type of assistanceDietSpecial diet required?(Required) Yes No Type of special dietFood allergies?(Required) Yes No Type of food allergyProblems with Eating(Required) Chewing Swallowing Dental None Other Type of problem eatingNeeds at meals(Required) Cut up food Puree Supplement Close monitoring N/A IMPORTANT: This form is not complete until you hit submit at the end. Karl Fagerstrom Nicotine Tolerance QuestionnaireDo you smoke cigarettes?(Required) Yes No I have been a non-smoker(number of years)For each statement, circle the most appropriate number that best describes you.How many cigarettes do you smoke per day? 10 or less 11-20 21-30 31 or more How soon after you wake up do you smoke your first cigarette? 0-5 min 30 min 31-60 min after 60 min Do you find it difficult to refrain from smoking in places where smoking is not allowed?(e.g., hospitals, government offices, cinemas, libraries, etc) Yes No Do you smoke more during the first hours after waking than during the rest of the day? Yes No Which cigarette would you be the most unwilling to give up? First in the morning Any of the others Do you smoke even when you are very ill? Yes No IMPORTANT: This form is not complete until you hit submit at the end. SPOP 360 Dear SPOP client, our mission is to improve the mental health and well-being of older New Yorkers. With this in mind, we have created the SPOP360 screening tool to identify needs outside of behavioral health that our clients may have. We are not a care management program; our goal is to use this information to link clients to other service providers who are able to address their identified needs, including housing, food, medical care, or social isolation.HousingIn the past year, have you been(Required)(check all that apply) Unhoused Threatened with eviction In transitional temporary or substandard housing, and/or current rent/mortgage payment is unaffordable Other housing issues None OtherWould you like assistance with any of the above?(Required) Yes No Income/ExpensesIn the past year, have you been(Required)(check all that apply) Been without income Had inadequate income to meet your basic needs Had outstanding medical bills Experienced your utility company shutting off your service because your bills were not paid Been unable to manage debt or struggled with inappropriate spending habits Had other financial problems (please explain briefly) None OtherWould you like assistance with any of the above?(Required) Yes No TransportationIn the past year, have you been(Required)(check all that apply) Had any problems with finding, scheduling, or paying for reliable transportation that has prevented you from getting to medical appointments or getting things needed for daily living Had difficulty using public transportation due to a medical or psychiatric issue Other (please explain briefly) None OtherWould you like assistance with any of the above?(Required) Yes No FoodIn the past year, have you(Required)(check all that apply) Ever had a time during the month when you don’t have enough food Worried that food would run out before you got money to buy more Eaten smaller meals or skipped meals because you don’t have money for food Had any other difficulty preparing meals due to medical or physical condition Other (please explain briefly) None OtherWould you like assistance with any of the above?(Required) Yes No Community and Social SupportIn the past year, have you(Required)(check all that apply) Felt lonely and had no one to call when you needed help or support Needed help with day-to-day activities such as dressing, cleaning, or doing laundry Found yourself wanting to volunteer, participate, or otherwise engage in community-based activities but didn’t know who to call and where to go Other (please explain briefly) None OtherWould you like assistance with any of the above?(Required) Yes No IMPORTANT: This form is not complete until you hit submit at the end. Insurance(Required)If your insurance is through Medicare or Medicaid, please check below. Medicare Medicaid Neither Authorization for Access to Patient Information New York State Department of Health Through a Health Information Exchange OrganizationIf you have insurance through Medicare, we need the following fields completed separately.Name First Last Date of Birth Month Day Year Address Street Address City State Zip Code I request that health information regarding my care and treatment be accessed as set forth on this form. I can choose whether or not to allow to obtain access to my medical records through the health information exchange organization called Healthix. If I give consent, my medical records from different places where I get health care can be accessed using a statewide computer network. Healthix is a not-for-profit organization that shares information about people’s health electronically to Service Program for Older People (SPOP) improve the quality of healthcare and meets the privacy and security standards of HIPAA, the requirements of the federal confidentiality laws, 42 CFR Part2, and New York State Law. To learn more visit Healthix’s website at www.healthix.org. The choice I make in this form will NOT affect my ability to get medical care. The choice I make in this form does NOT allow health insurers to have access to my information for the purpose of deciding whether to provide me with health insurance coverage or pay my medical bills.My Consent Choice.(Required)ONE box is checked to the left of my choice. I can fill out this form now or in the future. I can also change my decision at any time by completing a new form. 1. I GIVE CONSENT for to access ALL of my electronic health information through Healthix to provide health care. 2. I DENY CONSENT for to access my electronic health information through Healthix for any purpose. If I want to deny consent for all Provider Organizations and Health Plans participating in Healthix to access my electronic health information through Healthix, I may do so by visiting Healthix’s website at www.healthix.org or calling Healthix at 877-695-4749. My questions about this form have been answered and I have been provided a copy of this form.Signature of Patient or Patient’s Legal Representative(Required)Date Month Day Year Print Name of Legal Representative (if applicable)Relationship of Legal Representative to Patient (if applicable)Details about the information accessed through Healthix and the consent process: How Your Information May be Used. Your electronic health information will be used only for the following healthcare services: Treatment Services. Provide you with medical treatment and relatedservices. Insurance Eligibility Verification. Check whether you have health insurance and what it covers. Care Management Activities. These include assisting you in obtaining appropriate medical care, improving the quality of services provided to you, coordinating the provision of multiple health care services provided to you, or supporting you in following a plan of medical care. Quality Improvement Activities. Evaluate and improve the quality of medical care provided to you and all patients. What Types of Information about You Are Included. If you give consent, the Provider Organization listed may access ALL of your electronic health information available through Healthix. This includes information created before and after the date this form is signed. Your health records may include a history of illnesses or injuries you have had (like diabetes or a broken bone), test results (like X-rays or blood tests), and lists of medicines you have taken. This information may include sensitive health conditions, including but not limited to: – Alcohol or drug use problems – Birth control and abortion (family planning) – Genetic (inherited) diseases or tests – HIV/AIDS – Mental health conditions – Sexually transmitted diseases – Medication and Dosages – Diagnostic Information – Allergies – Substance use history summaries – Clinical notes – Discharge summary – Employment Information – Living Situation – Social Supports – Claims Encounter Data – Lab Test Where Health Information About You Comes From. Information about you comes from places that have provided you with medical care or health insurance. These may include hospitals, physicians, pharmacies, clinical laboratories, health insurers, the Medicaid program, and other organizations that exchange health information electronically. A complete, current list is available from Healthix. You can obtain an updated list at any time by Healthix’s website at www.healthix.org or by calling 877-695-4749. Who May Access Information About You, If You Give Consent. Only doctors and other staff members of the Organization(s) you have given consent to access who carry out activities permitted by this form as described above in paragraph one. Public Health and Organ Procurement Organization Access. Federal, state or local public health agencies and certain organ procurement organizations are authorized by law to access health information without a patient’s consent for certain public health and organ transplant purposes. These entities may access your information through Healthix for these purposes without regard to whether you give consent, deny consent or do not fill out a consent form. Penalties for Improper Access to or Use of Your Information. There are penalties for inappropriate access to or use of your electronic health information. If at any time you suspect that someone who should not have seen or gotten access to information about you has done so, call Service Program for Older People (SPOP) at (212) 787-7120; or visit Healthix’swebsite: www.healthix.org; or call the NYS Department of Health at 518-474-4987; or follow the complaint process of the federal Office for Civil Rights at the following link: http://www.hhs.gov/ocr/privacy/hipaa/complaints/. Re-disclosure of Information. Any organization(s) you have given consent to access health information about you may re-disclose your health information, but only to the extent permitted by state and federal laws and regulations. Alcohol/drug treatment-related information or confidential HIV-related information may only be accessed and may only be re-disclosed if accompanied by the required statements regarding prohibition of re-disclosure. Effective Period. This Consent Form will remain in effect until the day you change your consent choice, in case of a minor until he/she turns 18 years of age, or until 50 years after your death or until such time as Healthix ceases operation. If Healthix merges with another Qualified Entity your consent choices will remain effective with the newly merged entity. Changing Your Consent Choice. You can change your consent choice at any time and for any Provider Organization or Health Plan by submitting a new Consent Form with your new choice. Organizations that access your health information through Healthix while your consent is in effect may copy or include your information in their own medical records. Even if you later decide to change your consent decision they are not required to return your information or remove it from their records. Copy of Form.You are entitled to get a copy of this ConsentForm. PSYCKES Consent formIf you have insurance through Medicaid, we need the following fields completed separately.About PSYCKES The New York State (NYS) Office of Mental Health maintains the Psychiatric Services and Clinical Knowledge Enhancement System (PSYCKES). This online database stores some of your medical history and other information about your health. It can help your health providers deliver the right care when you need it. The information in PSYCKES comes from your medical records, the NYS Medicaid database and other sources. Go to www.psyckes.org, and click on About PSYCKES, to learn more about the program and where your data comes from. This data includes: Your name, date of birth, address and other information that identifies you; Your health services paid for by Medicaid; Your health care history, such as illnesses or injuries treated, test results and medicines; Other information you or your health providers enter into the system, such as a health Safety Plan. What You Need to Do Your information is confidential, meaning others need permission to see it. Complete this form now or at any time if you want to give or deny your providers access to your records. What you choose will not affect your right to medical care or health insurance coverage. Choose: “I GIVE CONSENT” if you want the provider, and their staff involved in your care, to see your PSYCKES information. “I DON’T GIVE CONSENT” if you don’t want them to see it. If you don’t give consent, there are some times when this provider may be able to see your health information in PSYCKES – or get it from another provider – when state and federal laws and regulations allow it.1 For example, if Medicaid is concerned about the quality of your health care, your provider may get access to PSYCKES to help them determine if you are getting the right care at the right time. 1 Laws and regulations include NY Mental Hygiene Law Section 33.13, NY Public Health Law Article 27-F, and federal confidentiality rules, including 42 CFR Part 2 and 45 CFR Parts 160 and 164 (also referred to as “HIPAA”).Your Choice. Please check 1 box only.(Required) I GIVE CONSENT for the provider, and their staff involved in my care, to access my health information in connection with my health care services. I DON’T GIVE CONSENT for this provider to access my health information, but I understand they may be able to see it when state and federal laws and regulations allow it. Print Name of Patient(Required)Patient’s Date of Birth(Required) Month Day Year Signature of Patient or Patient’s Legal Representative(Required)Date Month Day Year Name of Legal Representative (if applicable)Relationship of Legal Representative (if applicable)PSYCKES Information and Consent How providers can use your health information. They can use it only to: Provide medical treatment, care coordination, and related services. Evaluate and improve the quality of medical care. Notify your treatment providers in an emergency (e.g., you go to an emergency room). What information they can access. If you give consent, Service Program for Older People (SPOP) can see ALL your health information in PSYCKES. This can include information from your health records, such as illnesses or injuries (for example, diabetes or a broken bone), test results (X- rays, blood tests, or screenings), assessment results, and medications. It may include care plans, safety plans, and psychiatric advanced directives you and your treatment provider develop. This information also may relate to sensitive health conditions, including but not limited to: Mental health conditions Alcohol or drug use Birth control and abortion (family planning) Genetic (inherited) diseases or tests HIV/AIDS Sexually transmitted diseases Where the information comes from. Any of your health services paid for by Medicaid will be part of your record. So are services you received from a state-operated psychiatric center. Some, but not all information from your medical records is stored in PSYCKES, as is data you and your doctor enter. Your online record includes your health information from other NYS databases, and new databases may be added. For the current list of data sources and more information about PSYCKES, go to:www.psyckes.org and see “About PSYCKES”, or ask your provider to print the list for you. Who can access your information, with your consent. SPOP’s doctors and other staff involved in your care, as well as health care providers who are covering or on call for SPOP. Staff members who perform the duties listed in #1 above also can access your information. Improper access or use of your information. There are penalties for improper access to or use of your PSYCKES health information. If you ever suspect that someone has seen or accessed your information – and they shouldn’t have – call: SPOP at (212) 787-7120, or the NYS Office of Mental Health Customer Relations at 800-597-8481. Sharing of your information. SPOP may share your health information with others only when state or federal law and regulations allow it. This is true for health information in electronic or paper form. Some state and federal laws also provide special protections and additional requirements for disclosing sensitive health information, such as HIV/AIDS, and drug and alcohol treatment.1 Effective period.This Consent Form is in effect for 3 years after the last date you received services from SPOP, or until the day you withdraw your consent, whichever comes first. Withdrawing your consent.You can withdraw your consent at any time by signing and submitting a Withdrawal of Consent Form to SPOP. You also can change your consent choices by signing a new Consent Form at any time. You can get these forms at www.psyckes.org or from your provider by calling SPOP at (212) 787-7120. Please note, providers who get your health information through SPOP while this Consent Form is in effect may copy or include your information in their medical records. If you withdraw your consent, they don’t have to return the information or remove it from their records. Copy of form. You can receive a copy of this Consent Form after you sign it. IMPORTANT: This form is not complete until you hit submit at the end. Your Name(Required) First Last File uploadPlease upload a copy of your photo ID and insurance card(s). Drop files here or Select files Accepted file types: jpg, png, pdf, Max. file size: 100 MB. IMPORTANT: You must hit submit to complete this form.CAPTCHA