PSYCKE CONSENT FORM
After speaking with our intake coordinator (212-838-4333 ext. 137), please provide us with the following information.
Answers are not saved until you click the final “Submit” button at the bottom of the page. Until that point, you can review and change any answers as needed.
- How providers can use your health information. They can use it only to:
- Provide medical treatment, care coordination, and related
- Evaluate and improve the quality of medical
- Notify your treatment providers in an emergency (e.g., you go to an emergency room).
- What information they can access. If you give consent, Karen Horney Clinic 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
- 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. Karen Horney Clinic’s doctors and other staff involved in your care, as well as health care providers who are covering or on call for Karen Horney Clinic. 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:
- email@example.com at Karen Horney Clinic, or
- the NYS Office of Mental Health Customer Relations at 800-597-8481.
- Sharing of your information. Karen Horney Clinic 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 Karen Horney Clinic, 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 TheClinic@karenhorneyclinic.org. 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 212-838-4333 at Karen Horney Clinic. Please note, providers who get your health information through Karen Horney Clinic 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.
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”).