Benefits & HIPAA
In order for me to obtain reimbursement support services under NeuroStar Reimbursement Support program, I
understand that Neuronetics, its affiliates and authorized agents administering the program (including third party
administrators) (“Neuronetics”) will need to receive, review, use and disclose information about me, my health
insurance coverage, and my medical diagnosis and treatment (including my use of or need for NeuroStar TME
Therapy). I request and authorize my physician and other healthcare professionals (“Doctor(s)) and my health plan
or insurance company (“Insurer(s)”) to give Neuronetics information about me, my health insurance coverage, and
my medical diagnosis and treatment (including my use of or need to use NeuroStar TMS Therapy). This
information can include spoken or written facts about my health and payment benefits, as well as copies of
records from Doctor(s) or Insurer(s) about my health or healthcare. I understand that I may revoke this
Authorization by sending a written notice to my Doctor(s) and Neuronetics. Revocation of this Authorization will
be valid when received by my Doctor(s) and Neuronetics, except to the extent that my Doctor(s) and/or
Neuronetics have already taken action relying on this Authorization. I also understand that my revoking this
Authorization will not affect my health care treatment or enrollment under a health plan. I also understand the
information disclosed because of this Authorization may be re-disclosed by the recipient and may not be protected
by the federal or state privacy regulations. Neuronetics may be required by contract to protect the confidentiality
of this information but otherwise does not assume any responsibility for the information submitted. Neuronetics is
providing its services “AS IS” without representations or warranties of any kind, express or implied, and cannot and
does not accept any liability including for any inability to obtain coverage or reimbursement for me.
In no event shall Neuronetics be liable for any direct, indirect, consequential, incidental, special or exemplary
damaged of any kind or nature arising out of the services. I hereby authorize Neuronetics to use the information
described above for purpose of assisting to gain access and reimbursement for NeuroStar TMS Therapy.
All reimbursement information provided by Neuronetics is for general guidance only. It does not represent a
statement, promise or guarantee by Neuronetics concerning levels of reimbursement, payment, or change, if any.
Coverage and payment for NeuroStar TMS Therapy is based on various s factors, including but not limited to;
medical necessity, the patient’s specific benefits plan, and individual insurance company’s policies and guidelines.
It is the responsibility of the physician and patient to be knowledgeable of the applicable guidelines.
The Healing House keeps medical information about you. This information is personal and private. We utilize this information for a
number of reasons. We use the information when we treat you within our organization or refer you for treatment elsewhere (to co-
ordinate care outside of our organization, we will have you complete an Authorization to Release / Obtain Information form). We
also use this information to feed into our health care operations and to help maximize quality assurance.
**Please note that operations include our providers sharing your information amongst themselves in order to facilitate collaborative
care, a practice that is driven by the objective of best suiting the individual needs of our clients.
Under healthcare law, each client has certain rights to the medical information kept by The Healing House – TMS Therapy. These
Access - You can request to view your medical information.
Restriction - You can ask to limit who has access to your medical information. You can ask to limit what information is sent out
of The Healing House
Accounting - You can request to review the list of places where your medical information has been sent.
Amending - You can request that changes be made to your medical information if you feel that there are inaccuracies.
A complete notice with explanations of uses, disclosures, rights and information on how to file a privacy complaint is available at
A client also has the right to file a complaint regarding privacy of their medical information with the Secretary of Health and Hu-
man Services toll free at 1-877-696-6775.
Florida Statutes Florida statutorily grants patients the right of access to medical records maintained by health care practitioners.
The disclosure of client information by providers is generally prohibited without the client's consent, subject to specified exceptions.
Florida also has numerous laws protecting the confidentiality of health information held by a variety of entities and government
Notice of Privacy Practices Required by Federal Law Including Privacy Protections Under Florida State Law
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS
TO THIS INFORMATION.
PLEASE REVIEW IT CAREFULLY.
The Healing House
417 E. Jackson Street
Orlando, FL 32801 Basic Intake / HIPAA
Privacy Protection Under Florida State Law
The HIPAA Privacy rules are preempted by state law, which includes Florida Law.
Signed client consent is required for most communication of health information.
A summary report may be provided instead of complete psychotherapy notes.
In general, medical records may not be furnished to and the medical condition of a patient may not be discussed with any per-
son other than the patient, the client’s legal representative, or other health care practitioners and providers involved in the care
and treatment of the client without the client’s written authorization.
The HIPAA Privacy Practices
1. PURPOSE: The Healing House – TMS Therapy and its professional staff, employees, and trainees follow the privacy practices de-
scribed in this Notice. The Healing House – TMS Therapy keeps your mental health information in records that will be maintained
and protected in a confidential manner, as required by law. Please note that in order to provide you with the best possible care
and treatment, all professional staff involved in your treatment and employees involved in the health care operations of the agen-
cy may have access to your records.
2. WHAT ARE TREATMENT and HEALTH CARE OPERATIONS?
Your treatment includes sharing information among health care providers who are involved in your treatment. For example, if you
are seeing both a physician and a psychologist, they may share information in the process of coordinating your care. Treatment
records may be revealed as part of an on-going process directed toward assuring the quality of our operations. Staff dedicated to
quality assurance may access clinical records periodically to verify that our standards are met.
3. HOW WILL The Healing House – TMS Therapy USE MY PROTECTED HEALTH INFORMATION?
Your personal mental health record will be retained by The Healing House – TMS Therapy for approximately ten years after your last
clinical contact with our professional staff. After that time has elapsed, the record will be shredded or otherwise destroyed in a
way that protects your privacy. Until the records are destroyed they may be used, unless you request restrictions on a specific use
or disclosure, for the following purposes:
Notification when an appointment is cancelled or rescheduled by us;
As may be required by law;
For public health purposes such as reporting of child or elder abuse or neglect; reporting reactions to medications; infec
tious disease control; notifying authorities of suspected abuse, neglect, or domestic violence (if agreed or as required by
Mental health oversight activities, e.g., Audits, inspections or investigations of administration and management of The
Lawsuits and disputes (We will attempt to provide you advance notice of subpoena before disclosing information from
Law enforcement (e.g., in response to a court order or other legal process) to identify or locate an individual being sought
by authorities; about victim of a crime under restricted circumstances; about a death that may be the result of criminal
conduct; about criminal conduct that occurred in the facility; when emergency circumstances occur relating to a crime;
To prevent a serious threat to health or safety;
To carry out treatment and health care operations functions through transcription and billing services;
To military command authorities if you are a member of the armed forces or a member of a foreign military authority;
National security and intelligence activities;
Protection of the President or other authorized persons for foreign heads of state, or to conduct special investigations.
Progress Notes that are kept separate from the medical record enjoy special protection.
The term Progress Notes excludes medication prescription and monitoring, counseling session start and stop times, the modali-
ties and frequencies of treatment furnished, results of clinical tests, and any summary of the following items: diagnosis, func-
tional status, the treatment plan, symptoms, prognosis, and progress to date, employment, application, utilization, examina-
The Healing House
417 E. Jackson Street
Orlando, FL 32801 Basic Intake / HIPAA
4. Alcohol and drug abuse information has special privacy protections The Healing House will not disclose any information identify-
ing an individual as being a client or provide any mental health or medical information relating to a client's substance abuse treat-
ment unless: (i) the client consents in writing; (ii) a court order requires disclosure of the information; (iii) medical personnel need the
information to meet a medical emergency; (iv) qualified personnel use the information for the purpose of conducting research,
management audits, or program evaluation; or (v) it is necessary to report a crime or a threat to commit a crime or to report
abuse or neglect as required by law 4. YOUR AUTHORIZATION IS REQUIRED FOR OTHER DISCLOSURES. Except as described previous-
ly, The Healing House will not use or disclose information from your record unless you authorize in writing our facility to do so. You
may revoke your permission, which will be effective only after the date of your written revocation.
5. YOU HAVE RIGHTS REGARDING YOUR PROTECTED HEALTH INFORMATION.
You have the following rights regarding your health information, provided that you make a written request to invoke the right on
the form provided by The Healing House:
Right to request restriction. You may request limitations on your mental health information we may disclose, but we are not
required to agree to your request. If we agree, we will comply with your request unless the information is needed to provide
you with emergency treatment.
Right to confidential communications. You may request communications in a certain way or at a certain location, but you
must specify in writing how or where you wish to be contacted.
Right to inspect and copy. You have the right to inspect and copy your mental health information regarding decisions about
your care; however, Progress Notes may not be inspected and copied. We may charge a fee for copying, mailing, and sup-
plies. Under limited circumstances, your request may be denied; you may request review of the denial by another licensed
mental health professional chosen by The Healing House – will comply with the outcome of the review.
Right to request clarification of the record. If you believe that the information we have about you is incorrect or incomplete
you may ask to add further clarifying information. You may ask for a form for that purpose and the form will require certain spe-
cific information. The Healing House is not required to accept the information that you propose.
Right to accounting of disclosures. You may request a list of the disclosures of your mental health information that have been
made to persons or entities other than for treatment or health care operations..
Right to a copy of this Notice. You may request a paper copy of this Notice at any time, even if you have been provided with
an electronic copy.
6. REQUIREMENTS REGARDING THIS NOTICE.
The Healing House is required to provide you with this Notice that governs your privacy practices. The Healing House may change
its policies or procedures in regard to privacy practices. If and when changes occur, the changes will be effective for mental
health information we have about you as well as any information we receive in the future. Any time you come in to The Healing
House for an appointment, you may ask for and receive a copy of the Privacy Notice that is in effect at the time. You may also
retrieve a copy of further Client Rights upon request, which discusses client rights within the scope of the HH core values and how
they relate to the federal/statutory law outlined above.
If you believe your privacy rights have been violated, you may file a complaint with The Healing House. You will not be penalized
or retaliated against in any way for making a complaint.
Contact: Please call one of your individual providers or The Healing House to discuss issues of privacy. If you have a request regard-
ing this notice and would like to place restrictions on uses and disclosure for health care treatment or operations, you may obtain
any of the forms mentioned to exercise your individual rights described above.