Terms of Use*

By using this website and all other related services, you must read and agree to the following use terms, consents and policies as stated below:

You must be 20 years or older and reside in the following U.S. states: New York, Florida, Pennsylvania or Iowa.

Telehealth / Telemedicine Patient Informed Consent

Please be informed that certain conditions which are diagnosed on an in-person visit may not be detected remotely through telemedicine. For some people several evaluation visits and additional requested testing may be required. Alternatives to telepsychiatry services, including any delays in obtaining in-person service, need to travel, or risks associated with not having the services provided by telemedicine or telepsychiatry.

Special regulations do not allow for telehealth prescription of pain medications, muscle relaxants, sedatives, stimulants, narcotic medications (including benzodiazepines, tramadol, gabapentin and ephedrine stimulants) and medications for erectile dysfunction.

There are professional guidelines on the use, treatment and monitoring of prescribed psycho-pharmaceutical medications. Individual responses and tolerability for these medications may vary. Outside of accessing your medical records and claim receipts for telehealth visits, additional forms or letters shall not be completed or issued by this provider.

You must agree that your providing telehealth physician determines whether your condition, testing, diagnosis or treatment is appropriate for telemedicine encounters. You agree to participate in your treatment as indicated and to seek immediate or urgent care from local mental health

providers or emergency facilities when directed to do so by your telehealth provider or if you are unable to reach your telehealth provider, and to call 911 in an emergency. You agree to hold your telehealth provider and his associates harmless for information lost due to any technical failures

or for your diverging from the indicated treatment plan. All fees for professional services rendered are non-refundable and they due at the time of your visit. We do not approve, endorse or guarantee any services, products, information and recommendations provided by other third-party websites. This policy may be updated without notice.

Your Insurance Plan Benefits And Out-Of-Network Provider Payment Agreement (No Surprise Act)

Every health insurance plan has specific benefits and financial obligations. You are responsible for any cost-sharing your plan has established. Please be aware that your insurance plan may have specified limitations and exclusions to certain medical or provider services. Kindly inquire with your insurance about all the benefits, cost-sharing, exclusions, and limitations of your plan before you seek services, to avoid unnecessary or unexpected expenses. The allowed amount is the maximum amount your insurance plan will pay for a covered health care service. Balance billing is when a non-participating provider’s fees are more than the allowed amount, and you receive a bill for the difference. Your plan may not cover you in part or in full for non-emergency services from out-of-network doctors. By utilizing this site and the practice’s telehealth provider services, scheduling a telehealth session, you hereby agree with your own free will to be responsible for your in-network cost-sharing amounts and for the full cost of out-of-network rendered professional services. PRIVATE TELEHEALTH PRACTICE FEE POLICY: The initial private consultation fee is estimated at $400 up to 60 minutes and $150 will be applied for each additional 15 minutes of provider services as indicated based on clinical considerations, including for any assistance with required coordination of care services. The fee for subsequent sessions is estimated at $300 for the first 45 minutes and $150 for each additional 15 minutes of provider services as indicated based on clinical considerations, including for any assistance with required coordination of care services. All fees are payable at the time of the session. This practice has a 24-cancellation or no show policy with a charge of $150 per occurrence to which you hereby agree upon the scheduling of each of your sessions. For additional inquiries please call 212-660-2911.

Your Information. Your Rights. Our Responsibilities.
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.
Your Rights
You have the right to:
• Get a copy of your paper or electronic medical record
• Correct your paper or electronic medical record
• Request confidential communication
• Ask us to limit the information we share
• Get a list of those with whom we’ve shared your information
• Get a copy of this privacy notice
• Choose someone to act for you
• File a complaint if you believe your privacy rights have been violated
Your Choices
You have some choices in the way that we use and share information as we:
• Tell family and friends about your condition
• Provide disaster relief
• Include you in a hospital directory
• Provide mental health care
• Market our services and sell your information
• Raise funds
Our Uses and Disclosures
We may use and share your information as we:
• Treat you
• Run our organization
• Bill for your services
• Help with public health and safety issues
• Do research
• Comply with the law
• Respond to organ and tissue donation requests
• Work with a medical examiner or funeral director
• Address workers’ compensation, law enforcement, and other government requests
• Respond to lawsuits and legal actions
Your Health Information Rights
When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.
Your Information. Your Rights. Our Responsibilities.
Get an electronic or paper copy of your medical record
• You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this.
• We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.
Ask us to correct your medical record
• You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this.
• We may say “no” to your request, but we’ll tell you why in writing within 60 days.
Request confidential communications
• You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.
• We will say “yes” to all reasonable requests.
Ask us to limit what we use or share
• You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say “no” if it would affect your care.
• If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say “yes” unless a law requires us to share that information.
Get a list of those with whom we’ve shared information
• You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why.
• We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.
Get a copy of this privacy notice
You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.
Choose someone to act for you
• If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.
• We will make sure the person has this authority and can act for you before we take any action.
Your Information. Your Rights. Our Responsibilities.
File a complaint if you feel your rights are violated
• You can complain if you feel we have violated your rights by contacting us using the information on page 1.
• You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/.
• We will not retaliate against you for filing a complaint.
Your Choices
For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.
In these cases, you have both the right and choice to tell us to:
• Share information with your family, close friends, or others involved in your care
• Share information in a disaster relief situation
• Include your information in a hospital directory
If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.
In these cases we never share your information unless you give us written permission:
• Marketing purposes
• Sale of your information
• Most sharing of psychotherapy notes
In the case of fundraising:
• We may contact you for fundraising efforts, but you can tell us not to contact you again.
Our Uses and Disclosures
How do we typically use or share your health information?
We typically use or share your health information in the following ways.
Treat you
We can use your health information and share it with other professionals who are treating you.
Example: A doctor treating you for an injury asks another doctor about your overall health condition.
Run our organization
Your Information. Your Rights. Our Responsibilities.
We can use and share your health information to run our practice, improve your care, and contact you when necessary. Example: We use health information about you to manage your treatment and services.
Bill for your services
We can use and share your health information to bill and get payment from health plans or other entities.
Example: We give information about you to your health insurance plan so it will pay for your services.
How else can we use or share your health information?
We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.
Help with public health and safety issues
We can share health information about you for certain situations such as:
• Preventing disease
• Helping with product recalls
• Reporting adverse reactions to medications
• Reporting suspected abuse, neglect, or domestic violence
• Preventing or reducing a serious threat to anyone’s health or safety
Do research
We can use or share your information for health research.
Comply with the law
We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law.
Respond to organ and tissue donation requests
We can share health information about you with organ procurement organizations.
Work with a medical examiner or funeral director
We can share health information with a coroner, medical examiner, or funeral director when an individual die.
Address workers’ compensation, law enforcement, and other government requests
We can use or share health information about you:
• For workers’ compensation claims
• For law enforcement purposes or with a law enforcement official
• With health oversight agencies for activities authorized by law
• For special government functions such as military, national security, and presidential protective services
Respond to lawsuits and legal actions
Your Information. Your Rights. Our Responsibilities.
We can share health information about you in response to a court or administrative order, or in response to a subpoena.
Our Responsibilities
• We are required by law to maintain the privacy and security of your protected health information.
• We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
• We must follow the duties and privacy practices described in this notice and give you a copy of it.
• We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.
For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.
Changes to the Terms of this Notice
We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our web site.
Other Instructions for Notice
• Privacy official (or other privacy contact): Dr. Ronald Liteanu. Phone: (212) 660-2911. Email: drron@bewelldr.com. (Note: This email is not intended for any clinical communication or use.)
Permitted Uses or Disclosures of PHI Without Authorization:
The Privacy Rule permits us to use or disclose PHI, without the authorization of the individual who is the subject of the protected information.
These purposes include, but are not limited to, the following:
• A covered entity may disclose PHI to the individual who is the subject of the information.
• A covered entity may use and disclose protected health information for its own “treatment, payment, and health care operations.”
o Treatment is the provision, coordination, or management of health care and related services for an individual, including consultation between providers and referral of an individual to another provider for health care.
o Payment includes activities of a health care provider to obtain payment or to receive reimbursement for the provision of health care to an individual.
o Health care operations include functions such as: (a) quality assessment and improvement; (b) competency assessment, including performance evaluation,
Your Information. Your Rights. Our Responsibilities.
credentialing, and accreditation; (c) medical reviews, audits, or legal services; (d) specified insurance functions; and (e) business planning, management, and general administration.
• Permission may be obtained from the individual who is the subject of the information or by circumstances that clearly indicate an individual with capacity has the opportunity to object to the disclosure but does not express an objection. Providers may also rely on an individual's informal permission to disclose health information to an individual's family, relatives, close personal friends, or to other persons identified by the individual, limited to information directly related to such person's involvement.
• When an individual is incapacitated or in an emergency, providers sometimes may use or disclose PHI, without authorization, when it is in the best interests of the individual, as determined by health care provider in the exercise of clinical judgment. The PHI that may be disclosed under this provision includes the patient's name, location in a health care provider's facility, and limited and general information regarding the person's condition.
• Providers may use and disclose PHI without a person's authorization when the use or disclosure of PHI is required by law, including State statute or court order.
• Providers generally may disclose PHI to State and Federal public health authorities to prevent or control disease, injury, or disability, and to government authorities authorized to receive reports of child abuse and neglect.
• Providers may disclose PHI to appropriate government authorities in limited circumstances regarding victims of abuse, neglect, or domestic violence.
• Providers may disclose PHI to health oversight agencies, (e.g., the government agency which licenses the provider), for legally authorized health oversight activities, such as audits and investigations.
• PHI may be disclosed in a judicial or administrative proceeding if the request is pursuant to a court order, subpoena, or other lawful process (note that "more stringent" NYS Mental Hygiene law requires a court order for disclosure of mental health information in these circumstances).
• Providers may generally disclose PHI to law enforcement when:
o Required by law, or pursuant to a court order, subpoena, or an “administrative request,” such as a subpoena or summons (Note: the "more stringent" NYS Mental Hygiene Law section 33.13 requires a court order for disclosure of mental health information in these circumstances). The information sought must be relevant and limited to the inquiry.
o To identify or locate a suspect, fugitive, material witness or missing person (Note: under Mental Hygiene Law section 33.13 this information is limited to “identifying data concerning hospitalization”).
o In response to a law enforcement request for information about a victim of a crime (Note: under Mental Hygiene Law section 33.13 this information is limited to “identifying data concerning hospitalization”).
o To alert law enforcement about criminal conduct on the premises of a HIPAA covered entity.
• Providers may disclose PHI that they believe necessary to prevent or lessen a
o serious and imminent physical threat to a person or the public, when such disclosure is made to someone they believe can prevent or lessen the threat (including the target of the threat).
• An authorization is not required to use or disclose PHI to certain government
o programs providing public benefits or for enrollment in government benefit
Your Information. Your Rights. Our Responsibilities.
o programs if the sharing of information is required or expressly authorized by statute or regulation, or other limited circumstances
Minimum Necessary Rule:
We must make reasonable efforts to use, request, or disclose to others only the minimum amount of PHI which is needed to accomplish the intended purpose of the use, request or disclosure. When the minimum necessary standard applies, we may not use, disclose, or request a person's entire medical record, unless it can specifically justify that the entire record is reasonably needed.
The minimum necessary standard does not apply under the following circumstances:
• disclosure to a health care provider for treatment;
• disclosure to an individual (or personal representative) who is the subject of the information;
• use or disclosure made pursuant to an Authorization by the person (or personal representative);
• use or disclosure that is required by law; or
• disclosure to HHS for investigation, compliance review or enforcement.