PSYCKE CONSENT WITHDRAWAL FORM

What you need to know
You previously signed a Consent Form, giving this health care provider permission to access your Medicaid and other health information available in the Psychiatric Services and Clinical
Enhancement System (PSYCKES) online database.

You must complete and sign this Consent Withdrawal Form if you no longer want this provider, and their staff who provide your care, to see your information. When you complete, sign and return this form to them:

  1. This health care provider won’t be able to access your health information through PSYCKES. The exceptions are:
    1. in an emergency, or
    2. when state and federal confidentiality laws and regulations allow it. 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
  2. Your provider may be able to access your medical information in other ways. For example, the same laws and regulations may allow them to get information needed to treat you from another provider.
  3. This Withdrawal of Consent will not affect the health information shared while your Consent was in effect.
  4. Your access to medical care and health insurance coverage won’t change because you withdrew consent. Your health care providers will still submit claims to your insurer for the services you receive.
  5. You can complete a new PSYCKES Consent Form at any time. Forms are available from your provider and, once completed and signed, should be returned to them.
  6. You’ll get a copy of this form when you sign and submit 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”).