WyoKids Therapy Forms
New Patients
All new patients will need to complete the New Patient Form and Medical Record Release and bring them with you to your first appointment. Our Notice of Privacy Practices can be downloaded by clicking on the Privacy Practices button or by continuing down on this page. The Model Release is a form that may be used to gain permission to use images and/or video for promotional and other purposes (not required).
All new patients will need to complete the New Patient Form and Medical Record Release and bring them with you to your first appointment. Our Notice of Privacy Practices can be downloaded by clicking on the Privacy Practices button or by continuing down on this page. The Model Release is a form that may be used to gain permission to use images and/or video for promotional and other purposes (not required).
Referring Providers
Policy and Procedure On Notification Of Privacy Rights Under The Health Insurance Portability and Accountability Act (HIPAA)
Policy: It is the policy of WyoKids Therapy that all staff and families will understand their right to privacy under the Health Insurance Portability and Accountability Act (HIPAA).
Purpose: To ensure each family member’s right to privacy under HIPAA.
Procedure: The following steps are to be followed to inform employees and families concerning their privacy rights under HIPAA:
NOTICE OF PRIVACY PRACTICES
Effective Date: March 1, 2021
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.
Protecting Your Privacy
WyoKids Therapy provides many types of health-related services such as counseling, occupational therapy, physical therapy, speech language therapy, vision services, referrals for medical assessments, and billing to Medicaid or private insurance. WyoKids Therapy is required by both state and federal law to maintain the privacy of its clients’ protected health information (PHI), to provide notice of its legal duties and privacy practices with respect to PHI to its clients, and to notify affected individuals following a breach of unsecured PHI.
We Safeguard the Information We Collect About Your Child
We are required by law to provide you with this notice explaining WyoKids Therapy’s privacy practices with regard to your child’s medical information and how we may use and disclose your child’s PHI for treatment, payment, and for health care operations, as well as for other purposes that are permitted or required by law. You have certain rights regarding the privacy of your child’s protected health information and we also describe those rights in this notice.
We follow strict physical and technical security standards and procedures to help prevent unauthorized access to personal information. Only authorized employees may access information we collect from or about your child. We apply rigorous standards for protection of personal information to all our interactions with you and your child, including those conducted via the internet.
WyoKids Therapy reserves the right to change the provisions of our Notice and make new provisions effective for all PHI we maintain. If WyoKids Therapy makes a material change to our Notice, we will post the changes promptly on our website at http://therapy.wyokids.org.
HITECH Notification Requirements
Under HITECH, WyoKids Therapy is required to notify clients whose PHI has been breached. Notification must occur by first class mail within 60 days of the event. A breach occurs when an unauthorized use or disclosure that compromises the privacy or security of PHI poses a significant risk for financial, reputational, or other harm to the individual. This notice must:
Use and Disclosures Without Your Authorization
Uses and Disclosures That Require Your Written Authorization
Your PHI Privacy Rights
How to Contact WyoKids Therapy to Review, Correct, or Restrict Your PHI
You may ask the WyoKids Therapy office to:
WyoKids Therapy may deny your request to look at, copy or change your records. If WyoKids Therapy denies your request, WyoKids Therapy will send you a letter explaining why your request is being denied and how to ask for a review of the denial. You will also receive information about how to file a complaint with WyoKids Therapy or with the U.S. Department of Health and Human Services.
How to File a Complaint or Report a Problem
You may contact the person listed below if you want to file a complaint or report a problem with how WyoKids Therapy has used or disclosed your PHI. Your child’s services will not be affected by any complaints you make. WyoKids Therapy cannot retaliate against you for filing a complaint, cooperating in an investigation, or refusing to agree to something you believe is unlawful. You must submit this complaint to Developmental Preschool and Day Care Center/WyoKids Therapy, Jaime Stine, Executive Director, 1771 Centennial Drive, Laramie, WY 82070, (307)742-3571, [email protected]. To file a complaint with the United States Secretary of Health and Human Services, send your complaint to him/her in care of: Office of Civil Rights, U.S. Department of Health and Human Services, 200 Independence Avenue, SW, Washington, D.C. 20201.
For More Information
If you have any questions about this notice or need more information, please contact the WyoKids Therapy Executive Director.
Developmental Preschool and Day Care Center/WyoKids Therapy
Jaime Stine, Executive Director
1771 Centennial Drive, Laramie, WY 82070
(307)742-3571
[email protected]
http://therapy.wyokids.or
Policy: It is the policy of WyoKids Therapy that all staff and families will understand their right to privacy under the Health Insurance Portability and Accountability Act (HIPAA).
Purpose: To ensure each family member’s right to privacy under HIPAA.
Procedure: The following steps are to be followed to inform employees and families concerning their privacy rights under HIPAA:
- Upon intake of a family or employment of a new staff member, provision of a Notice of Privacy Rights under the Health Insurance Portability and Privacy Act (HIPPA) will be provided. Signed acknowledgment of receipt of Notice of Privacy Practices will be obtained.
- Current employees and families will also be provided with the Notice of Privacy Practices under HIPAA which will also include signed acknowledgment of receipt of these Rights.
- Signed acknowledgment will be maintained in each employee’s personnel file and the files of all enrolled children.
- WyoKids Therapy will continue to follow current practices of confidentiality in order to maintain confidentiality of staff and families.
NOTICE OF PRIVACY PRACTICES
Effective Date: March 1, 2021
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.
Protecting Your Privacy
WyoKids Therapy provides many types of health-related services such as counseling, occupational therapy, physical therapy, speech language therapy, vision services, referrals for medical assessments, and billing to Medicaid or private insurance. WyoKids Therapy is required by both state and federal law to maintain the privacy of its clients’ protected health information (PHI), to provide notice of its legal duties and privacy practices with respect to PHI to its clients, and to notify affected individuals following a breach of unsecured PHI.
We Safeguard the Information We Collect About Your Child
We are required by law to provide you with this notice explaining WyoKids Therapy’s privacy practices with regard to your child’s medical information and how we may use and disclose your child’s PHI for treatment, payment, and for health care operations, as well as for other purposes that are permitted or required by law. You have certain rights regarding the privacy of your child’s protected health information and we also describe those rights in this notice.
We follow strict physical and technical security standards and procedures to help prevent unauthorized access to personal information. Only authorized employees may access information we collect from or about your child. We apply rigorous standards for protection of personal information to all our interactions with you and your child, including those conducted via the internet.
WyoKids Therapy reserves the right to change the provisions of our Notice and make new provisions effective for all PHI we maintain. If WyoKids Therapy makes a material change to our Notice, we will post the changes promptly on our website at http://therapy.wyokids.org.
HITECH Notification Requirements
Under HITECH, WyoKids Therapy is required to notify clients whose PHI has been breached. Notification must occur by first class mail within 60 days of the event. A breach occurs when an unauthorized use or disclosure that compromises the privacy or security of PHI poses a significant risk for financial, reputational, or other harm to the individual. This notice must:
- Contain a brief description of what happened, including the date of the breach and the date of discovery;
- The steps the individual should take to protect themselves from potential harm resulting from the breach;
- A brief description of what WyoKids Therapy is doing to investigate the breach, mitigate losses, and to protect against further breaches.
Use and Disclosures Without Your Authorization
- For treatment. WyoKids Therapy may use or disclose information about your child to provide, coordinate or manage your child’s evaluation and services provided by us and other service providers. We may disclose health information about your child to doctors, nurses, case managers, psychologists, social workers, direct support staff and other agency staff, teachers and other persons who are involved in supporting your child or providing care. We may consult with other health care providers concerning your child and, as part of the consultation, share health information with them. For example, staff may discuss information to develop and carry out your child’s individual service plan. Staff my share information to coordinate needed services, such as medical tests, transportation to a doctor’s visit, physical therapy, etc. Staff may need to disclose health information to entities outside of our organization, for example another provider or a state/local agency to obtain additional services for your child.
- For payment. WyoKids Therapy may use or disclose PHI to receive payment or to pay for the health care services your child receives. This can include billing a third party payer, such as Medicaid or your insurance company. This can also include providing necessary information to other providers for payment on your behalf for services provided to your child.
- For health care operations. WyoKids Therapy may use or disclose PHI to manage its programs and activities. For example, WyoKids Therapy may use PHI to review the quality of the services your child receives.
- For appointments and informative purposes. WyoKids Therapy may send you reminders for appointments for services and meetings. WyoKids Therapy may send you information about health services that may be of interest to you.
- For public health activities. WyoKids Therapy may use or disclose PHI to maintain vital records and track some diseases as required by law.
- As required by law and for law enforcement. WyoKids Therapy may disclose PHI when required by law or court order, or pursuant to law enforcement investigations.
- For government programs. WyoKids Therapy may disclose PHI to other government programs that manage eligibility for public benefits/assistance.
- To avoid harm. WyoKids Therapy may disclose PHI to law enforcement to avert a serious threat to the health and safety of a person or the public.
- For research. WyoKids Therapy may use PHI to conduct studies and develop reports. However, these reports do not identify specific people.
Uses and Disclosures That Require Your Written Authorization
- For situations not previously listed. WyoKids Therapy will ask for your written authorization before using or disclosing your PHI. You may revoke this authorization in writing at any time. WyoKids Therapy cannot take back any uses or disclosures already made with your authorization.
- Uses and disclosures which specifically require your authorization. Except in limited circumstances, WyoKids Therapy must obtain your written authorization prior to any uses or disclosures of psychotherapy notes, of PHI for marketing purposes, or of PHI for the sale of that PHI. For marketing or sale of PHI, the authorization must inform you if WyoKids Therapy will receive direct or indirect payment from a third party.
- Other laws protect PHI. Many WyoKids Therapy programs are subject to additional laws regarding the use and disclosure of your health information. For example, you must give written authorization for WyoKids Therapy to use and disclose your mental health and chemical dependency treatment records.
Your PHI Privacy Rights
- Right to see and get copies of your records. In most cases, you have the right to look at or get copies of your child’s records. You must make the request in writing. You may be charged a fee for the cost of copying your child’s records.
- Right to request to correct or update your records. If you feel your child’s records are inaccurate, you may ask WyoKids Therapy to change or add missing information. You must make the request in writing, and provide a reason for your request. WyoKids Therapy is not required to agree to the request.
- Right to get a list of disclosures. You have the right to ask WyoKids Therapy for a list of disclosures of your child’s PHI made within the last six (6) years. You must make the request in writing.
- Right to request restrictions on uses or disclosures of your PHI. You have the right to ask WyoKids Therapy to restrict how your child’s PHI is used or disclosed. You must make the request in writing and tell WyoKids Therapy what PHI you want to restrict and to whom you want the restriction to apply. WyoKids Therapy is generally not required to agree to a requested restriction. However, WyoKids Therapy must agree to your request to restrict uses and disclosures of PHI to a health plan (e.g., health insurance company) when you or someone other than the health plan has paid WyoKids Therapy for a health care item or service, unless the use or disclosure is required by law. Once a restriction is implemented, you can request either verbally or in writing that the restriction be terminated.
- Right to revoke permission. If you are asked to sign an authorization to use or disclose your PHI, you may cancel the authorization at any time. You must make the request in writing. This will not affect PHI already shared by WyoKids Therapy.
- Right to choose how we communicate with you. You have the right to ask WyoKids Therapy to share information with you in a certain way or in a certain place. For example, you may ask WyoKids Therapy to send information to your work address instead of your home address. You must make this request in writing. You do not need to explain the reason for your request.
- Right to file a complaint. You have the right to file a complaint if you do not agree with how WyoKids Therapy has used or disclosed information about your child.
- Right to get a paper copy of this notice. You have the right to ask for a paper copy of this notice at any time.
How to Contact WyoKids Therapy to Review, Correct, or Restrict Your PHI
You may ask the WyoKids Therapy office to:
- look at or copy your child’s records;
- correct or change your child’s records;
- restrict uses or disclosures of your child’s PHI;
- list of the times WyoKids Therapy disclosed your child’s PHI;
- revoke your authorization to disclose PHI; or
- file a complaint.
WyoKids Therapy may deny your request to look at, copy or change your records. If WyoKids Therapy denies your request, WyoKids Therapy will send you a letter explaining why your request is being denied and how to ask for a review of the denial. You will also receive information about how to file a complaint with WyoKids Therapy or with the U.S. Department of Health and Human Services.
How to File a Complaint or Report a Problem
You may contact the person listed below if you want to file a complaint or report a problem with how WyoKids Therapy has used or disclosed your PHI. Your child’s services will not be affected by any complaints you make. WyoKids Therapy cannot retaliate against you for filing a complaint, cooperating in an investigation, or refusing to agree to something you believe is unlawful. You must submit this complaint to Developmental Preschool and Day Care Center/WyoKids Therapy, Jaime Stine, Executive Director, 1771 Centennial Drive, Laramie, WY 82070, (307)742-3571, [email protected]. To file a complaint with the United States Secretary of Health and Human Services, send your complaint to him/her in care of: Office of Civil Rights, U.S. Department of Health and Human Services, 200 Independence Avenue, SW, Washington, D.C. 20201.
For More Information
If you have any questions about this notice or need more information, please contact the WyoKids Therapy Executive Director.
Developmental Preschool and Day Care Center/WyoKids Therapy
Jaime Stine, Executive Director
1771 Centennial Drive, Laramie, WY 82070
(307)742-3571
[email protected]
http://therapy.wyokids.or