WESTCHESTER INSTITUTE
FOR HUMAN DEVELOPMENT
Behavioral Psychology Program
Cedarwood Hall, Room 300A
Valhalla, NY 10595
BEHAVIORAL PSYCHOLOGY PROGRAM
REGISTRATION PACKET
Welcome to the Behavioral Psychology Program at Westchester Institute for Human Development
(WIHD). The attached forms must be completed prior to the patient's first appointment. This packet
includes:
1. DIRECTIONS – Directions to the Behavioral Psychology Program at WIHD.
2. PROGRAM INFORMATION – Brief overview of the Behavioral Psychology Program at WIHD.
3. **REGISTRATION FORM – This form provides the Behavioral Psychology Program at WIHD with
basic information about the patient. Please complete.
4. **SCREENING FORM – This form provides the Behavioral Psychology Program at WIHD with
information in regards to the patient's history and behavioral concerns. Please complete.
5. **CONSENT FOR CARE AND TREATMENT – This form indicates consent for the patient to
receive services at the Behavioral Psychology Program at WIHD. Please complete and sign.
6. **FINANCIAL AGREEMENTS – This form indicates the financial agreement between the patient
and the Behavioral Psychology Program at WIHD. Please complete and sign.
7. NOTICE OF PRIVACY PRACTICES – Information on how the Behavioral Psychology Program at
WIHD may use and share patient health information and how the patient can exercise their health
privacy rights.
8. **NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT – This form is to acknowledge
that the patient received the Notice of Privacy Practices. Please complete and sign.
9. PATIENT BILL OF RIGHTS – A list of rights that are guaranteed to the patient.
10. **PATIENT BILL OF RIGHTS ACKNOWLEDGEMENT – This form is to acknowledge that the
patient received the Patient Bill of Rights. Please complete and sign.
11. **AUTHORIZATION TO USE OR DISCLOSE PROTECTED HEALTH INFORMATION –
This form authorizes the Westchester Institute for Human Development to release health information to
designated individuals and/or organizations. Information from medical/psychological care cannot be
released without this form. Please complete and sign.
**PLEASE RETURN THE ** ITEMS ALONG WITH COPIES OF ALL CURRENT INSURANCE
CARDS (FRONT AND BACK) BY MAIL/FAX/EMAIL TO:
Behavioral Psychology Program
Westchester Institute for Human Development
Cedarwood Hall, Room 300A
Valhalla, New York 10595
Ph. (914) 493-7070
Fax. (914) 493-1973
[email protected]
Rev 3/2015
WESTCHESTER INSTITUTE
FOR HUMAN DEVELOPMENT
Behavioral Psychology Program
Cedarwood Hall, Room 300A
Valhalla, NY 10595
BEHAVIORAL PSYCHOLOGY PROGRAM
DIRECTIONS
By Car (GPS Address: 20 Hospital Oval West, Valhalla, NY)
From the Bronx and South:
Bronx River Parkway North to Sprain Brook Parkway North. Exit at Hawthorne/Westchester Medical Center exit.
Turn left onto Hospital Road. Continue straight at stop sign, following road past parking structure on your left, to
the end of the road. At stop sign, turn left onto Sunshine Cottage Road. Make second right onto Hospital Oval
West.*
From the North:
Taconic Parkway South to Medical Center/Route 100 exit (just past the New York State Police Headquarters).
Turn right at top of exit ramp onto Route 100 South. Turn right at light, passing over parkway. Continue straight
at stop sign, following road past parking structure on your left, to the end of the road. At stop sign, turn left onto
Sunshine Cottage Road. Make second right onto Hospital Oval West.*
From the West:
New York State Thruway South across Tappan Zee Bridge staying to the right as you go through tolls to Exit 8A
(87 South). Follow signs for Saw Mill Parkway North. Exit at Eastview, and turn right. Follow road through
business park, remaining on Route 100C (bear left) as road forks. At second light, make a left into the
Westchester Medical Center campus and follow road to stop sign at end. Turn left, following road past parking
structure on your left to the end of the road. At stop sign, turn left onto Sunshine Cottage Road. Make second
right onto Hospital Oval West.*
From the East:
Cross Westchester Expressway (287) Westbound to Exit 3 (Sprain Parkway). Bear left after exiting to
Northbound Sprain Parkway. Take Sprain Parkway north to Medical Center exit. Turn left onto Hospital Road.
Continue straight at stop sign, following road past parking structure on your left, to the end of the road. At stop
sign, turn left onto Sunshine Cottage Road. Make second right onto Hospital Oval West.*
*As you pass the parking lot, enter at the parking booth and take a ticket at the gate. The entrance to Cedarwood
Hall is directly opposite the parking lot. Once you enter Cedarwood Hall, make a right down the hall and the
elevators will be on the left. The Behavioral Psychology Department is on the 3rd floor.
By Train
Westchester Institute for Human Development is served by Metro North's Harlem Line via two stations:
White Plains: For train fare and schedule information, call 1-800-METRO-INFO. Once you arrive at the White
Plains stations, Westchester Institute for Human Development is about a 10-minute bus ride. There are three bus
lines (Westchester Bee Line) you can take to our campus. Please call 914-813-7777 for bus routes and fares.
Hawthorne: This station has a taxi stand that can provide taxi service directly to Westchester Institute for Human
Development.
By Bus
Westchester Institute for Human Development is serviced by several local bus companies, including the
Westchester Bee Line (914) 813-7777.
Rev 3/2014
WESTCHESTER INSTITUTE
FOR HUMAN DEVELOPMENT
Behavioral Psychology Program
Cedarwood Hall, Room 300A
Valhalla, NY 10595
BEHAVIORAL PSYCHOLOGY PROGRAM
PROGRAM INFORMATION
The Behavioral Psychology Program at Westchester Institute for Human Development is a
highly specialized program focused on providing behavioral therapy, school consultation, and parent
training to individuals, teachers, parents, and caregivers focusing on individuals with Autism
Spectrum Disorder and other developmental disabilities.
The main focus of the program is providing services for individuals who display challenging
behaviors (i.e., self-injury, aggression, property destruction) using an applied behavior analysis
(ABA) approach. The application of this approach includes individualized assessment and treatment
plans, objective behavioral data collection (i.e., direct observation) throughout the assessment and
intervention process, and evidence-based assessments and interventions.
The Behavioral Psychology Program also provides services to children without Autism Spectrum
Disorder or other developmental disability diagnoses who display challenging behaviors. Behavioral
parent-training services are provided to address behaviors such as not following directions,
aggression, tantrums, toileting difficulties, sleep difficulties, and problematic school behaviors.
Behavioral feeding therapy services are provided to increase the amount and range of foods (texture,
consistency, taste) a child will eat.
The licensed psychologists, who are also Board Certified Behavior Analysts (BCBAs), at the
Behavioral Psychology Program have extensive clinical experience and provide a high level of
supervision to program personnel. In addition, hands-on training is provided for parents, teachers,
and other caregivers, who are an integral part of the assessment and treatment process.
Stephanie Contrucci Kuhn, Ph.D., BCBA-D, Director
Stephanie Bader, Ph.D., BCBA
.org
Rev 7/2014
WESTCHESTER INSTITUTE
FOR HUMAN DEVELOPMENT
NAME
Cedarwood Hall
Valhalla, NY 10595-1689
D.O.B.
WMC #
WIHD#
REGISTRATION FORM
New Registration 
(For WIHD Use Only)
Registration Update 
Name
____________________________________
(First)
(Last)
Date of Birth __________________
Male 
Female 
Address ___________________________________________
Zip
Ethnicity:
Today’s Date
County
White 
(M.I.)
SS # _________________________
City ___________________
State
Phone
African American 
Mother’s Name
Hispanic 
Other Specify  __________________
_____ Home Phone
Work Phone
Mother’s Address ______________________________ City _______________ State _______
Father’s Name _________________________________ Home Phone
Zip __________
Work Phone
Father’s Address _______________________________ City _______________ State _______
______
______
Zip __________
Guardian/Foster Parent Name _____________________________________________________________________
Home Phone
_______________ _________
Work Phone
__________________________________
Guardian/Foster Parent Address ___________________________________________________________________
City ___________________________________________ State ___________
Medicaid No. __________________ Origination of Medicaid:
Zip __________
New York State 
Westchester County 
Other County (specify)  ________________
620/621 Eligible:
Yes 
No 
Not Sure 
Medicare No.
Private Insurance Co. _______________________________
Policy No.
Name of Insured ___________________________________
Relationship to Patient _____________________
Other Insurance Co. ________________________________
Policy No.
Name of Insured ___________________________________
Relationship to Patient _____________________
Agency/House Name
Contact
Address
City
Rev 1/2014
Phone No.
State
Zip
WESTCHESTER INSTITUTE Name: ____________________________
FOR HUMAN DEVELOPMENT
Behavioral Psychology Program
Cedarwood Hall, Room 300A
Valhalla, NY 10595
D.O.B.: ___________________________
WMC #_________
WIHD #_________
(For WIHD Use Only)
BEHAVIORAL PSYCHOLOGY PROGRAM
SCREENING FORM
Please complete and return this form to:
Behavioral Psychology Program
Westchester Institute for Human Development
Cedarwood Hall, Room 300A
Valhalla, NY 10595
Phone: (914) 493-7070
Fax: (914) 493-1973
Email: [email protected]
For the most complete evaluation, please provide these additional items (when possible):
1. The patient's most recent educational and psychological evaluations
2. All programs (previous and current) designed to treat target behaviors
3. The patient's typical daily schedule
Today’s Date:
Completed by:
PATIENT INFORMATION
Patient's Last Name:
Date of Birth:
First:
/
/
Patient Currently Lives at: (please check one)
Middle:
Sex:  M  F
Age:
 Home
 Residential Facility
Social Security Number:
Telephone: (
Address:
City:
Mother’s Last Name:
First:
Telephone: (
)
Mother's Address:
Alternate Phone: (
City:
Father's Last Name:
First:
Telephone: (
)
Father’s Address (if not same as above):
Alternate Phone: (
City:
School or Institution:
Address:
City:
Teacher’s Name:
 Other:____________
)
State:
ZIP Code:
Middle:
)
State:
ZIP Code:
Middle:
)
State:
Telephone: (
State:
)
ZIP Code:
Does the patient have a 1:1 aide?
Yes
 No
Number of teachers and aides in the classroom:
Number of students:
Has a skills assessment been conducted with the patient at school or by a service provider? Yes (please provide a copy of the report)
(For example: an ABLLS, VB-MAPP)
 No
Rev 6/2014
Type of School Placement:
ZIP Code:
Page 1 of 5
Referred by (please check one):
 Dr._______________________
 Family
 Friend
School
 Yellow Pages
 Hospital
 Self
 Other_____________________
Has the patient been seen before at WIHD?
Have other family members been seen before at WIHD?
 Yes  No
 Yes (relation:_______________)  No
If the patient is over 18, who has legal custody? (please check one)
Do you have legal documentation?
 Patient
 Parent
 Other
 Not Assigned Yet
 Yes  No
Contact Person (if different than above):
Telephone:
Emergency Contact?
(
)
 Yes  No
Address:
City:
State:
ZIP Code:
Primary Care Physician:
Address:
Telephone: (
State:
City:
)
ZIP Code:
PSYCHOSOCIAL BACKGROUND
Parents
Age
Education
Age
Gender
Occupation
Marital Status
Father
Mother
Guardian
Individuals who live with the patient:
Name
Relationship
Community agencies or contacts who provide services to the patient or family:
Agency
Contact/Telephone
MEDICAL HISTORY
Previous medical conditions and developmental diagnoses:
Height:
Current medical conditions:
Weight:
Current medical equipment used (e.g. feeding pump, wheelchair, walker):
Current medical treatments (e.g., dialysis, tube feeding, tracheotomy):
Current medications and reason for prescription:
Medication
Rev 6/2014
Reason for Prescription
Page 2 of 5
Nature of Service
PROBLEM BEHAVIORS
Record each problem behavior the patient displays and describe it specifically. Include any damage resulting from the problem behavior
either to the patient or others. Please rank in order of concern to yourself or other caretakers.
Problem Behavior
Description (Topography)
Frequency
Duration
Intensity
How is it performed?
How often does it occur
How long does it last
How damaging or
What does it look like?
per day/week/month?
when it occurs?
destructive is it?
Estimate the severity of the problem behavior of greatest concern (please check one):
 Mild
 Moderate
 Severe
How long has the patient been engaging in the problem behavior(s)?
 Within the
 More than
 More than
 More than
past 6 months
6 months but less
1 year but less
3 years but less
than 1 year
than 3 years
than 5 years
Estimate the general trend of the problem behavior(s) during the past year:  Increasing
 Life-Threatening
 More than
 More than
5 years but less
10 years
than 10 years
 Decreasing
 Stable
When is/are the problem behavior(s) likely to occur? (please check all that apply)
 When the patient is left alone or unattended
 Mealtimes
 Certain time of day __________________
 When demands are placed on the patient
 Dressing
 Other: ____________________________
 When there are a lot of people around
 Bathing
In what setting(s) do these behaviors occur?
 Home
 School
___________________________
 Community
Are there any occasions when the problem behavior(s) rarely or never occurs?
Describe:
 Yes
 Other________________
 No
Has the patient ever been sent to the hospital to treat an injury resulting from the behavior?  Yes
Describe:
 No
Has the patient ever sent someone else to the hospital to treat an injury resulting from the behavior?  Yes
Describe:
 No
Does the patient target particular adults/peers (if aggressive)?
Yes  No
How do others (parents, teachers, staff) typically respond when the patient engages in the problem behavior(s)?
(If a formal program is currently being implemented, refer to it here and attach a copy)
Rev 6/2014
Page 3 of 5
BEHAVIOR CHECKLIST
How does the patient communicate?
(please check all that apply)
 Verbally
 Pointing
 Sign Language
 Other:_____________
 Pictures
 Communication Device
Please list some things that the patient likes (for example: bubbles, music, TV shows, tickles, water, etc)
Please indicate which of the following are areas of concern:
1) Compliance and Following Directions
(for example: follows directions to come here, sit still, keep hands to self,
clean up, get the red cup, turn off the light)
When is this a concern:
 Never
 Often
 Sometimes
 Always
When is this a concern:
 Never
 Often
 Sometimes
 Always
When is this a concern:
 Never
 Often
 Sometimes
 Always
When is this a concern:
 Never
 Often
 Sometimes
 Always
When is this a concern:
 Never
 Often
 Sometimes
 Always
When is this a concern:
 Never
 Often
 Sometimes
 Always
When is this a concern:
 Never
 Often
 Sometimes
 Always
 Never
 Often
 Sometimes
 Always
Please describe your concerns in this area:
2) Independent Living Skills
(for example: toileting, dressing, feeding self, drinking from a cup,
brushing teeth, eating too fast or slow)
Please describe your concerns in this area:
3) Rituals and Routines
(for example: difficulties changing from one activity to another, difficulty
when unexpected or expected changes occur)
Please describe your concerns in this area:
4) Academic Skills
(for example: matching, math, reading, telling time, identifying colors,
numbers, or letters)
Please describe your concerns in this area:
5) Social Skills or Social Awareness
(for example: imitating others, responding to greetings, taking turns,
asking and answering questions)
Please describe your concerns in this area:
6) Communication
(for example: making eye contact, using verbal language, pointing, sign
language, or pictures to express wants and needs)
Please describe your concerns in this area:
7) Play and Leisure
(for example: playing with toys, able to keep self busy for a period of
time, sharing, taking turns)
Please describe your concerns in this area:
8) Restrictive Behavior
(for example: will not eat a variety of foods, will not play with a variety of When is this a concern:
toys, will only wear certain clothing)
Please describe your concerns in this area:
Rev 6/2014
Page 4 of 5
9) Repetitive Behavior
(for example: engages in repetitive motor movements, “stims;” engages in When is this a concern:
repetitive verbal statements, scripting or perseverations)
Please describe your concerns in this area:
 Never
 Often
 Sometimes
 Always
10) Other (please describe)
 Never
 Often
 Sometimes
 Always
When is this a concern:
Please describe your concerns in this area:
Please describe any other concerns you have regarding the patient's learning or behavior:
Please describe specific skills you would like the patient to be taught:
Please describe your immediate goals for the patient while participating in treatment:
Please describe your long term goals for the patient while participating in treatment:
Please provide any other information that may be relevant to treatment:
Rev 6/2014
Page 5 of 5
WESTCHESTER INSTITUTE Name: ____________________________
FOR HUMAN DEVELOPMENT
Behavioral Psychology Program
Cedarwood Hall, Room 300A
Valhalla, NY 10595
D.O.B.: ___________________________
WMC #_________
WIHD #_________
(For WIHD Use Only)
BEHAVIORAL PSYCHOLOGY PROGRAM
CONSENT FOR CARE AND TREATMENT
1. I hereby authorize
to participate in outpatient care and treatment at
the Westchester Institute for Human Development, and the professionals, assisted by the employees of the
Institute, to provide such care.
2. I acknowledge that no guarantees or assurances have been made to me concerning the results or findings
intended from the treatment(s) or examination(s) at the Westchester Institute for Human Development.
3. I confirm that I have read and fully understand the above, have been given the opportunity to ask questions,
and that all my questions have been answered fully and to my satisfaction.
Patient/Relative or Guardian*
Signature of Patient or Personal Representative
Print Name of Patient or Personal Representative
Date
Description of Personal Representative’s Authority
Interpreter (if required)
Signature
Print Name
*Patient must sign unless he/she is an unemancipated minor under the age of 18 or lacks the capacity to
understand what is being signed.
THIS DOCUMENT MUST BE MADE PART OF THE PATIENT’S MEDICAL RECORD.
Rev 3/2014
WESTCHESTER INSTITUTE Name: ____________________________
FOR HUMAN DEVELOPMENT
Behavioral Psychology Program
Cedarwood Hall, Room 300A
Valhalla, NY 10595
D.O.B.: ___________________________
WMC #_________
WIHD #_________
(For WIHD Use Only)
BEHAVIORAL PSYCHOLOGY PROGRAM
FINANCIAL AGREEMENTS
Assignment of Benefits and Guarantee of Payment:
I UNDERSTAND THAT I AM FINANCIALLY RESPONSIBLE TO THE ABOVE-NAMED INSTITUTE
FOR ALL CHARGES, INCLUDING THOSE NOT PAID BY INSURERS OR THIRD PARTIES,
INCURRED BY ME OR IN MY BEHALF. I understand that the charges incurred will be billed at the rate of
$185 per hour for services. I understand that this is a fee-for-service agreement, and although I may submit
bills to my insurance carrier, I am responsible for payment in full regardless of insurance coverage for any
services.
DATE:
SIGNATURE:
Patient or Personal Representative
IF PERSON OTHER THAN PATIENT SIGNS, INDICATE RELATIONSHIP TO PATIENT AND
REASON FOR LACK OF PATIENT SIGNATURE:
I HAVE READ THIS AGREEMENT, AND I FULLY UNDERSTAND ITS NATURE AND
SIGNIFICANCE. I HAVE RETAINED A COPY OF THIS AGREEMENT.
DATE:
SIGNATURE:
Patient or Personal Representative (parent if minor)
Rev 2/2014
WESTCHESTER INSTITUTE FOR HUMAN DEVELOPMENT
NOTICE OF PRIVACY PRACTICES
Effective Date: July 1, 2005
Revised Date: March 2013
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED
AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE
REVIEW THIS NOTICE CAREFULLY.
Westchester Institute for Human Development (WIHD) is required by law to protect the privacy of health
information that may reveal your identity, and to provide you with a copy of this notice that describes the
health information privacy practices of our hospital, its medical staff, and affiliated health care providers that
jointly provide health care services with our hospital. A copy of our current notice will be posted in public
areas throughout the hospital. You will also be able to obtain additional copies by accessing our website at
www.wcmc.com, or by asking for one at the time of your next visit.
If you have any questions about this notice or would like further information, please contact the WIHD
Medical Director at 914.493.8170.
WHO WILL FOLLOW THIS NOTICE?
Westchester Institute for Human Development provides health care to patients jointly with physicians and
other health care professionals. The privacy practices described in this notice will be followed by:




Any health care professional who treats you at any of our sites (WIHD Cedarwood Hall; WIHD
Mobile Dental Van);
All employees, medical staff, trainees, students or volunteers at any of our sites;
All affiliated medical staff and their employees that are part of an Organized Health Care
Arrangement with the Westchester County Health Care Corporation;
Any business associates of our facility (which is described further below).
IMPORTANT SUMMARY INFORMATION
Requirement for Written Authorization. WIHD will generally obtain your written authorization before
using your health information or sharing it with others outside the institute. You may also initiate the
transfer of your records to another person by completing a written authorization form. If you provide us with
written authorization, you may revoke that written authorization at any time, except to the extent that we
have already complied with your request. To revoke a written authorization, please write to the Director of
Medical Records, WIHD, Cedarwood Hall Second Floor, Valhalla, New York 10595.
Exceptions to Written Authorization Requirement. There are some situations when we do not need your
written authorization before using your health information or sharing it with others. They are:

Exception for Treatment, Payment, and Business Operations. We may use and disclose your
health information to treat your condition, collect payment for that treatment, or run our business
operations. In some cases, we also may disclose your health information to another health care
provider or payor for its payment activities and certain of its business operations. For more
information, see pages 4-5 of this notice.
1

Exception For Disclosure to Family and Friends Involved In Your Care. We may include
information about you in our Facility Directory or share your health information with family and
friends involved in your care. Although we are not required to obtain your written authorization, we
will ask you whether you have any objection to the use or disclosure of your health information in
this way. For more information, see page 5 of this notice.

Exception For Public Need. We may use or disclose your health information in certain situations to
comply with the law or to meet important public needs. For example, we may share your
information with public health officials at New York State or other health departments who are
authorized to investigate and control the spread of diseases. For more examples, see pages 5-7 of
this notice.

Exception If Information Is Completely Or Partially De-Identified. We may use or disclose your
health information if we have removed any information that might identify you so that the health
information is "completely de-identified." We may also use and disclose "partially de-identified"
information if the person who will receive the information agrees in writing to protect the privacy of
the information. For more information, please see page 7 of this notice.
How to Access Your Health Information. You generally have the right to inspect and copy your health
information. For more information, please see page 7 of this notice.
How to Correct Your Health Information. You have the right to request that we amend your health
information if you believe it is inaccurate or incomplete. For more information, please see page 8 of this
notice.
How to Identify Others Who Have Received Your Health Information. You have the right to receive an
"accounting of disclosures," which identifies certain persons or organizations to which we have disclosed
your health information in accordance with the protections described in this Notice of Privacy Practices.
Many routine disclosures we make will not be included in this accounting, but the accounting will identify
many non-routine disclosures of your information. For more information, please see page 8-9 of this notice.
How to Request Additional Privacy Protections. You have the right to request further restrictions on the
way we use your health information or share it with others. We are not required to agree to the restriction
you request, but if we do, we will be bound by our agreement. For more information, please see page 9 of
this notice.
How to Request More Confidential Communications. You have the right to request that we contact you
in a way that is more confidential for you, such as at home instead of at work. We will try to accommodate
all reasonable requests. For more information, please see page 9 of this notice.
How Someone May Act On Your Behalf. You have the right to name a personal representative who may
act on your behalf to control the privacy of your health information. Parents will generally have the right to
control the privacy of health information about minors unless the minors are permitted by law to act on their
own behalf. If a guardian has been appointed, that guardian may act on your behalf, consistent with the
powers granted by the court.
How to Learn About Special Protections For HIV, Alcohol and Substance Abuse, Mental Health and
Genetic Information. Special privacy protections apply to HIV-related information, alcohol and substance
abuse treatment information, mental health information, and genetic information. Some parts of this general
Notice of Privacy Practices may not apply to these types of information. If your treatment involves this
2
information, you will be provided with separate notices explaining how the information will be protected. To
request copies of these other notices now, please contact the Medical Director at 914 493-8170.
How to Obtain a Copy of This Notice. You may request a paper copy of this notice at any time, even if
you have previously agreed to receive this notice electronically. To do so, please call the Medical Records
Department at 914 493-8651. You may also obtain a copy of this notice from our website at www.wihd.org
or by requesting a copy at your next visit.
How to Obtain a Copy of Revised Notice. We may change our privacy practices from time to time. If we
do, we will revise this notice so you will have an accurate summary of our practices. The revised notice will
apply to all of your health information. We will post any revised notice throughout our facility. You will
also be able to obtain your own copy of the revised notice by accessing our website at www.wihd.org, or
asking for one at the time of your next visit. The effective date of the notice will always be noted in the top
right comer of the first page. We are required to abide by the terms of the notice that is currently in effect.
How to File a Complaint. If you believe your privacy rights have been violated, you may file a complaint
with us or with the Secretary of the Department of Health and Human Services. To file a complaint with us,
please contact the Medical Director, Westchester Institute for Human Development, Cedarwood Hall, Room
221, Valhalla, New York 10595 or call the Medical Director at 914.493.8170. No one will retaliate or take
action against you for filing a complaint.
WHAT HEALTH INFORMATION IS PROTECTED
WIHD is committed to protecting the privacy of information we gather about you while providing healthrelated services. Some examples of protected health information are:




information indicating that you are a patient at WIHD or receiving treatment or other health- related
services from our facility;
information about your health condition (such as a disease you may have);
information about health care products or services you have received or may receive in the future
(such as an operation); or
information about your health care benefits under an insurance plan (such as whether a prescription
is covered);
when combined with:



demographic information (such as your name, address, or insurance status);
unique numbers that may identify you (such as your social security number, your phone number, or
your driver's license number); and
other types of information that may identify who you are.
3
HOW WE MAY USE AND DISCLOSE YOUR HEALTH INFORMATION WITHOUT YOUR
WRITTEN AUTHORIZATION
For your information, we have included below a more detailed explanation of how WIHD may use and
disclose your health information without your written authorization.
1. Treatment, Payment And Business Operations: We may use your health information or share it with
others in order to treat your condition, obtain payment for that treatment, and run our business operations.
In some cases, we may also disclose your health information for payment activities and certain business
operations of another health care provider or payor. Below are further examples of how your information
may be used and disclosed for these purposes.
Treatment. We may share your health information with doctors or nurses at another facility who are
involved in taking care of you, and they may in turn use that information to diagnose or treat you. A doctor
at our facility may share your health information with another doctor inside our facility, or with a doctor at
another hospital, to determine how to diagnose or treat you. Your doctor may also share your health
information with another doctor to whom you have been referred for further health care.
Payment. We may use your health information or share it with others so that we may obtain payment for
your health care services. For example, we may share information about you with your health insurance
company in order to obtain reimbursement after we have treated you, or to determine whether it will cover
your treatment. We might also need to inform your health insurance company about your health condition in
order to obtain pre-approval for your treatment, such as admitting you to the hospital for a particular type of
surgery. Finally, we may share your information with other health care providers and payors for their
payment activities.
Business Operations. We may use your health information or share it with others in order to conduct our
business operations. For example, we may use your health information to evaluate the performance of our
staff in caring for you, or to educate our staff on how to improve the care they provide for you. Finally, we
may share your health information with other health care providers and payors for certain of their business
operations if the information is related to a relationship the provider or payor currently has or previously had
with you, and if the provider or payor is required by federal law to protect the privacy of your health
information.
Appointment Reminders, Treatment Alternatives, Benefits And Services. In the course of providing
treatment to you, we may use your health information to contact you with a reminder that you have an
appointment for treatment or services at our facility. We may also use your health information in order to
recommend possible treatment alternatives or health-related benefits and services that may be of interest to
you.
Fundraising. To support our business operations, we may use demographic information about you,
including information about your age and gender, where you live or work, and the dates that you received
treatment, in order to contact you to raise money to help us operate. We may also share this information
with a charitable foundation that will contact you to raise money on our behalf.
You have the right to opt-out from any and all fundraising communications from WIHD. If you wish to optout you can send an email to [email protected] or call 914-493-1344.
Business Associates. We may disclose your health information to contractors, agents and other business
associates who need the information in order to assist us with obtaining payment or carrying out our
business operations. For example, we may share your health information with a billing company that helps
4
us to obtain payment from your insurance company. Another example is that we may share your health
information with an accounting firm or law firm that provides professional advice to us about how to
improve our health care services and comply with the law. If we do disclose your health information to a
business associate, we will have a written contract to ensure that our business associate also protects the
privacy of your health information.
2. Family and Friends: We may disclose your health information to family and friends involved in your
care. We will always give you an opportunity to object unless there is insufficient time because of a medical
emergency (in which case we will discuss your preferences with you as soon as the emergency is over). We
will follow your wishes unless we are required by law to do otherwise.
Family and Friends Involved In Your Care. If you do not object, we may share your health information
with a family member, relative, or close personal friend who is involved in your care or payment for that
care. We may also notify a family member, personal representative or another person responsible for your
care about your general condition here at the institute, or about the unfortunate event of your death. In some
cases, we may need to share your information with a disaster relief organization that will help us notify these
persons.
3. Public Need: We may use your health information, and share it with others, to comply with the law or to
meet important public needs that are described below.
As Required By Law. We may use or disclose your health information if we are required by law to do so.
We also will notify you of these uses and disclosures if notice is required by law.
Public Health Activities. We may disclose your health information to authorized public health officials (or
a foreign government agency collaborating with such officials) so they may carry out their public health
activities. For example, we may share your health information with government officials that are
responsible for controlling disease, injury or disability. We may also disclose your health information to a
person who may have been exposed to a communicable disease or be at risk for contracting or spreading the
disease if a law permits us to do so. And finally, we may release some health information about you to your
employer if your employer hires us to provide you with a physical exam and we discover that you have a
work- related injury or disease that your employer must know about in order to comply with employment
laws.
Victims Of Abuse, Neglect Or Domestic Violence. We may release your health information to a public
health authority that is authorized to receive reports of abuse, neglect or domestic violence. For example, we
may report your information to government officials if we reasonably believe that you have been a victim of
such abuse, neglect or domestic violence. We will make every effort to obtain your permission before
releasing this information, but in some cases we may be required or authorized to act without your
permission.
Health Oversight Activities. We may release your health information to government agencies authorized to
conduct audits, investigations, and inspections of our facility. These government agencies monitor the
operation of the health care system, government benefit programs such as Medicare and Medicaid, and
compliance with government regulatory programs and civil rights laws.
Product Monitoring, Repair And Recall. We may disclose your health information to a person or
company that is regulated by the Food and Drug Administration for the purpose of. (1) reporting or tracking
product defects or problems; (2) repairing, replacing, or recalling defective or dangerous products; or (3)
monitoring the performance of a product after it has been approved for use by the general public.
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Lawsuits And Disputes. We may disclose your health information if we are ordered to do so by a court or
administrative tribunal that is handling a lawsuit or other dispute.
Law Enforcement. We may disclose your health information to law enforcement officials for the following
reasons:
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To comply with court orders or laws that we are required to follow;
To assist law enforcement officers with identifying or locating a suspect, fugitive, witness, or missing
person;
If you have been the victim of a crime and we determine that: (1) we have been unable to obtain your
agreement because of an emergency or your incapacity; (2) law enforcement officials need this
information immediately to carry out their law enforcement duties; and (3) in our professional
judgment disclosure to these officers is in your best interests;
If we suspect that your death resulted from criminal conduct;
If necessary to report a crime that occurred on our property; or
If necessary to report a crime discovered during an offsite medical emergency (for example, by
emergency medical technicians at the scene of a crime).
To Avert a Serious and Imminent Threat to Health or Safety. We may use your health information or
share it with others when necessary to prevent a serious and imminent threat to your health or safety, or the
health or safety of another person or the public. In such cases, we will only share your information with
someone able to help prevent the threat. We may also disclose your health information to law enforcement
officers if you tell us that you participated in a violent crime that may have caused serious physical harm to,
another person (unless you admitted that fact while in counseling), or if we determine that you escaped from
lawful custody (such as a prison or mental health institution).
National Security and Intelligence Activities or Protective Services. We may disclose your health
information to authorized federal officials who are conducting national security and intelligence activities or
providing protective services to the President or other important officials.
Military and Veterans. If you are in the Armed Forces, we may disclose health information about you to
appropriate military command authorities for activities they deem necessary to carry out their military
mission. We may also release health information about foreign military personnel to the appropriate foreign
military authority.
Inmates and Correctional Institutions. If you are an inmate or you are detained by a law enforcement
officer, we may disclose your health information to the prison officers or law enforcement officers if
necessary to provide you with health care, or to maintain safety, security and good order at the place where
you are confined. This includes sharing information that is necessary to protect the health and safety of other
inmates or persons involved in supervising or transporting inmates
Workers' Compensation. We may disclose your health information for workers' compensation or similar
programs that provide benefits for work-related injuries.
Coroners, Medical Examiners and Funeral Directors. In the unfortunate event of your death, we may
disclose your health information to a coroner or medical examiner. This may be necessary, for example, to
determine the cause of death. We may also release this information to funeral directors as necessary to carry
out their duties.
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Organ and Tissue Donation. In the unfortunate event of your death, we may disclose your health
information to organizations that procure or store organs, eyes or other tissues so that these organizations
may investigate whether donation or transplantation is possible under applicable laws.
Research. In most cases, we will ask for your written authorization before using your health information or
sharing it with others in order to conduct research. However, under some circumstances, we may use and
disclose your health information without your written authorization if we obtain approval through a special
process to ensure that research without your written authorization poses minimal risk to your privacy. Under
no circumstances, however, would we allow researchers to use your name or identity publicly. We may also
release your health information without your written authorization to people who are preparing a future
research project, so long as any information identifying you does not leave our facility. In the unfortunate
event of your death, we may share your health information with people who are conducting research using
the information of deceased persons, as long as they agree not to remove from our facility any information
that identifies you.
4. Completely De-identified or Partially De-identified Information.
We may use and disclose your health information if we have removed any information that has the potential
to identify you so that the health information is "completely de-identified." We may also use and disclose
"partially de-identified" health information about you if the person who will receive the information signs an
agreement to protect the privacy of the information as required by federal and state law. Partially deidentified health information will not contain any information that would directly identify you (such as your
name, street address, social security number, phone number, fax number, electronic mail address, website
address, or license number).
5. Incidental Disclosures
While we will take reasonable steps to safeguard the privacy of your health information, certain disclosures
of your health information may occur during or as an unavoidable result of our otherwise permissible uses or
disclosures of your health information. For example, during the course of a treatment session, other patients
in the treatment area may see, or overhear discussion of, your health information.
6. Special Circumstances Requiring Authorization
The following uses and disclosures of PHI require authorization:
• Psychotherapy notes (where appropriate)
• Use and disclosure when accepting financial remuneration in exchange for marketing purposes
• Sale of your health information
YOUR RIGHTS TO ACCESS AND CONTROL YOUR HEALTH INFORMATION
We want you to know that you have the following rights to access and control your health information.
These rights are important because they will help you make sure that the health information we have about
you is accurate. They may also help you control the way we use your information and share it with others,
or the way we communicate with you about your medical matters.
1. Right to Inspect and Copy Records
You have the right to inspect and obtain a copy of any of your health information that may be used to make
decisions about you and your treatment for as long as we maintain this information in our records. This
includes medical and billing records. To inspect or obtain a copy of your health information, please submit
7
your request in writing to the Westchester Institute for Human Development, Medical Records, Cedarwood
Hall Second Floor, Valhalla, New York 10595. If you request a copy of the information, you may be
charged a reasonable fee for the costs of copying, mailing or other supplies we use to fulfill your request.
We will respond to your request for inspection of records within 10 days. We ordinarily will respond to
requests for copies within 30 days if the information is located in our facility, and within 60 days if it is
located off-site at another facility. If we need additional time to respond to a request for copies, we will
notify you in writing within the time frame above to explain the reason for the delay and when you can
expect to have a final answer to your request.
Under certain very limited circumstances, we may deny your request to inspect or obtain a copy of your
information. If we do, we will provide you with a summary of the information instead. We will also provide
a written notice that explains our reasons for providing only a summary, and a complete description of your
rights to have that decision reviewed and how you can exercise those rights. The notice will also include
information on how to file a complaint about these issues with us or with the Secretary of the Department of
Health and Human Services. If we have reason to deny only part of your request, we will provide complete
access to the remaining parts after excluding the information we cannot let you inspect or copy.
2. Right to Amend Records
If you believe that the health information we have about you is incorrect or incomplete, you may ask us to
amend the information. You have the right to request an amendment for as long as the information is kept in
our records. To request an amendment, please write to: Medical Records, WIHD, Cedarwood Hall Second
Floor, Valhalla, New York 10595. Your request should include the reasons why you think we should make
the amendment. Ordinarily we will respond to your request within 60 days. If we need additional time to
respond, we will notify you in writing within 60 days to explain the reason for the delay and when you can
expect to have a final answer to your request.
If we deny part or all of your request, we will provide a written notice that explains our reasons for doing so.
You will have the right to have certain information related to your requested amendment included in your
records. For example, if you disagree with our decision, you will have an opportunity to submit a statement
explaining your disagreement which we will include in your records. We will also include information on
how to file a complaint with us or with the Secretary of the Department of Health and Human Services.
These procedures will be explained in more detail in any written denial notice we send you.
3. Right to an Accounting of Disclosures
After April 14, 2003, you have a right to request an "accounting of disclosures" which identifies certain
other persons or organizations to whom we have disclosed your health information in accordance with
applicable law and the protections afforded in this Notice of Privacy Practices. An accounting of disclosures
does not describe the ways that your health information has been shared within the hospital, as long as all
other protections described in this Notice of Privacy Practices have been followed (such as obtaining the
required approvals before sharing your health information with our doctors for research purposes).
An accounting of disclosures also does not include information about the following disclosures:
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Disclosures we made to you or your personal representative;
Disclosures we made pursuant to your written authorization;
Disclosures we made for treatment, payment or business operations;
Disclosures made from the patient directory;
Disclosures made to your friends and family involved in your care or payment for your care;
8
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Disclosures that were incidental to permissible uses and disclosures of your health information (for
example, when information is overheard by another patient passing by);
Disclosures for purposes of research, public health or our business operations of limited portions of
your health information that do not directly identify you;
Disclosures made to federal officials for national security and intelligence activities;
Disclosures about inmates to correctional institutions or law enforcement officers;
Disclosures made before April 14, 2003.
To request an accounting of disclosures, please write to: Medical Records, Westchester Institute for Human
Development, Second Floor, Valhalla, New York 10595. Your request must state a time period within the
past six years (but after April 14, 2003) for the disclosures you want us to include. For example, you may
request a list of the disclosures that we made between July 1, 2005 and July 1, 2006. You have a right to
receive one accounting within every 12 month period for free. However, we may charge you for the cost of
providing any additional accounting in that same 12 month period. We will always notify you of any cost
involved so that you may choose to withdraw or modify your request before any costs are incurred.
Ordinarily we will respond to your request for an accounting within 60 days. If we need additional time to
prepare the accounting you have requested, we will notify you in writing about the reason for the delay and
the date when you can expect to receive the accounting. In rare cases, we may have to delay providing you
with the accounting without notifying you because a law enforcement official or government agency has
asked us to do so.
4. Right to Request Additional Privacy Protections
You have the right to request that we further restrict the way we use and disclose your health information to
treat your condition, collect payment for that treatment, or run our business operations. You may also
request that we limit how we disclose information about you to family or friends involved in your care.
For example, you could request that we not disclose information about a surgery you had. To request
restrictions, please write to the Medical Director, Westchester Institute for Human Development, Cedarwood
Hall Room 221, Valhalla, New York 10595. Your request should include (1) what information you want to
limit; (2) whether you want to limit how we use the information, how we share it with others, or both; and
(3) to whom you want the limits to apply.
We are not required to agree to your request for a restriction, and in some cases the restriction you request
may not be permitted under law. However, if we do agree, we will be bound by our agreement unless the
information is needed to provide you with emergency treatment or comply with the law. Once we have
agreed to a restriction, you have the right to revoke the restriction at any time. Under some circumstances,
we will also have the right to revoke the restriction as long as we notify you before doing so; in other cases,
we will need your permission before we can revoke the restriction.
5. Right to Restrict Certain Disclosure to a Health Plan
You have the right to restrict certain disclosures of your health information to a health insurance plan when
you pay out of pocket in full for the health care item or service. To request this restriction, please write to:
Medical Records, Westchester Institute for Human Development, Second Floor, Valhalla, New York 10595.
6. Right to Request Confidential Communications
You have the right to request that we communicate with you about your medical matters in a more
confidential way by requesting that we communicate with you by alternative means or at alternative
locations. For example, you may ask that we contact you at home instead of at work. To request more
9
confidential communications, please write to the Medical Director, Westchester Institute for Human
Development, Cedarwood Hall, Room 221, Valhalla, New York 10595. We will not ask you the reason for
your request, and we will try to accommodate all reasonable requests. Please specify in your request how or
where you wish to be contacted, and how payment for your health care will be handled if we communicate
with you through this alternative method or location.
7. Right to Be Notified of a Breach
You have the right to receive notification following a breach of unsecured protected health information if
you were deemed to be one of the affected individuals. You will be notified via letter if an impermissible
use and/or a risk assessment of a breach of your health information poses a significant risk of financial,
reputational, or other harm to you.
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WESTCHESTER INSTITUTE Name: ____________________________
FOR HUMAN DEVELOPMENT D.O.B.: ___________________________
Cedarwood Hall
Valhalla, NY 10595
WMC #_________
WIHD #_________
(For WIHD Use Only)
NOTICE OF PRIVACY PRACTICES
By signing below, I acknowledge that I have been provided a copy of this Notice of Privacy Practices and
have therefore been advised of how health information about me may be used and disclosed by the Institute and
the facilities listed at the beginning of this notice, and how I may obtain access to and control this information. I
also acknowledge and understand that I may request copies of separate notices explaining special privacy
protections that apply to HIV-related information, alcohol and substance abuse treatment information, mental
health information, and genetic information.
Signature of Patient or Personal Representative
Print Name of Patient or Personal Representative
Date
Description of Personal Representative’s Authority
Westchester Institute for Human
Development
Patient Bill of Rights
As a patient in New York State, you have the right, consistent with law, to:
1. Understand and use these rights. If for any reason you do not understand or you need help, WIHD
MUST provide assistance, including an interpreter.
2. Receive services without discrimination as to race, color, religion, sex, national origin, disability,
sexual orientation, source of payment, or age.
3. Be informed of all available services at WIHD.
4. Be informed of provisions for off-hour emergency coverage.
5. Be informed of the name and position of the physicians and any WIHD staff involved in your care at
WIHD.
6. Refuse treatment to the extent permitted by law and to be fully informed of the medical
consequences of this action.
7. Be informed of the charges for services, eligibility for third-party reimbursements and, when
applicable, the availability of free or reduced cost care.
8. Receive an itemized bill and explanation of all charges.
9. A non-smoking environment.
10. Receive complete information about your diagnosis, treatment and prognosis.
11. Receive all the information that you need to give informed consent for any proposed procedure or
treatment. This information shall include the possible risks and benefits of the procedure or
treatment.
12. Receive all the information you need to give informed consent for an order not to resuscitate. You
also have the right to designate an individual to give this consent for you if you are too ill to do so. If
WIHD Bill of Rights
7/2014
Page | 1
you would like additional information, please ask for a copy of the pamphlet “Deciding About Health
Care — A Guide for Patients and Families.”
13. Refuse treatment and be told what effect this may have on your health.
14. Refuse to take part in research. In deciding whether or not to participate, you have the right to a full
explanation.
15. Privacy while in the care of WIHD and confidentiality of all information and records regarding your
care.
16. Approve or refuse the release or disclosure of the contents of your medical record to any healthcare practitioner and/or health-care facility except as required by law or third-party payment
contract.
17. Review your medical record without charge. Obtain a copy of your medical record for which WIHD
can charge a reasonable fee. You cannot be denied a copy solely because you cannot afford to pay.
18. Complain without fear of reprisals about the care and services you are receiving and to have WIHD
respond to you and if you request it, a written response. To file a complaint if you are not happy
with the care you receive at WIHD you can contact an Administrator at:
Regulatory Compliance & Quality Improvement Office
Cedarwood Hall, Room 308
Valhalla, NY 10595
(914) 493-8367
[email protected]
If you are not satisfied with WIHD’s response, you can also contact the New York State Department of
Health:
New York State Department of Health
Centralized Hospital Intake Program
Mailstop: CA/DCS
Empire State Plaza
Albany, NY 12237
1-800-804-5447
WIHD Bill of Rights
7/2014
Page | 2
Westchester Institute for Human
Development
Patient Bill of Rights Acknowledgement
I acknowledge that I was provided a copy of the Patient Bill of Rights and that I have read, or have had
the opportunity to read, this Notice and I understand the Notice.
________________________________________________________________________
Patient Name (Please Print)
Date
________________________________________________________________________
Authorized Representative (Please print if applicable)
Relationship to Patient
X______________________________________________________________________
Patient’s or Authorized Representative’s Signature
WIHD Bill of Rights
7/2014
Page | 3
WESTCHESTER INSTITUTE Name: ____________________________
FOR HUMAN DEVELOPMENT
Behavioral Psychology Program
Cedarwood Hall, Room 300A
Valhalla, NY 10595
D.O.B.: ___________________________
WMC #_________ WIHD #_________
(For WIHD Use Only)
BEHAVIORAL PSYCHOLOGY PROGRAM
AUTHORIZATION TO USE OR DISCLOSE PROTECTED HEALTH INFORMATION
1. I authorize the Westchester Institute for Human Development (WIHD) to use or disclose the above-named
individual’s health information as follows. (Check the appropriate boxes and include other information where
indicated)
 Entire Record
 Problem List
 Most recent history/physical
 Immunization Records
 Medication List
 List of allergies
 Lab results (Indicate dates and/or specific tests) ____________________________________________
 X-ray/imaging reports (Indicate dates and/or specific tests)
 Consultation reports (Indicate physician/clinician names) _____________________________________
 Psychological and/or Behavioral Evaluations
 School Records
 Other (Please describe)
2. The information above may be used or disclosed to the following individuals or organization(s):
Name
Address
Name
Address
3. This information for which I’m authorizing disclosure will be used for the following purposes.
 My personal records
 Sharing with other healthcare providers as needed
 Sharing with school personnel including teachers, and related service providers (e.g. speech therapist,
occupational therapist, physical therapist, and psychologist)
 Other (please describe):
4. I understand that the information in my health record may include information relating to sexually transmitted
disease, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV). It may also
include information about behavioral or mental health services, and treatment for alcohol and drug abuse.
(See information below.)
a. Under New York State Law, confidential HIV-related information can only be given to people you
allow to have it by signing a written release, or to people who need to know your HIV status in order to
provide medical care and services, including: medical care provider; persons involved with foster care
or adoption; parents and guardians who consent to care of minors; jail, prison, probation and parole
Rev 2/2014
Page 1 of 2
employees; emergency response workers and other workers in the Institute, other regulated setting or
medical offices, who are exposed to blood/body fluids in the course of their employments and
organizations that review services you receive. The law also allows your HIV information to be
released under limited circumstances: by special court order to public health officials as required by
law; and to insurers as necessary to pay for care and treatment. Anyone who illegally discloses HIVrelated information may be punished by a fine up to $50,000 and a jail term of up to one year. If you are
requesting the release of HIV-related information, there is a separate form that must be completed.
b. I understand that my records are protected under the deferral regulations governing confidentiality or
Alcohol and Drug Abuse Patient Records, 42 CFR Part 2, and cannot be disclosed without my written
consent unless otherwise provided for in the regulations. A separate form is required for release of
this information.
c. All requests for disclosures of mental health information must be made in writing utilizing the
Authorization for Release of Information (State of New York Office of Mental Health, form OMH11).
5. I understand that I have a right to revoke this authorization at any time, except to the extent that the program
or person who is to make the disclosure has already acted in reliance on it. I understand that if I revoke this
authorization, I must do so in writing and present my written revocation to the Westchester Institute for
Human Development.
6. Unless I specify an expiration date or event, this authorization will expire three years from the date on which
it was signed.
7. I understand that once the above information is disclosed, it may be redisclosed by the recipient and the
information may not be protected by federal privacy laws or regulations.
8. I understand that authorizing the use or disclosure of the information identified above is voluntary. I
understand that I have the right to refuse to sign this form and that I need not sign this form to ensure
healthcare treatment, payment for my healthcare, or continuation of my healthcare benefits.
9. I understand that I have the right to inspect or copy information to be used or disclosed as described in this
form and in accordance with Institute policies and procedures. I have the right to receive a copy of this form
after I have signed it.
I have read this form and all of my questions have been answered to my satisfaction. By signing this form, I
acknowledge that I have read and accept all of the above.
Signature of Patient or Personal Representative
Print Name of Patient or Personal Representative
Date
Description of Personal Representative’s Authority
Fees
Copying, Films, and Distribution Costs. We reserve the right to charge you a reasonable fee to recover the costs
of copying, mailing, and supplies used to fulfill your request. Copies forwarded to a physician are free of charge.
Rev 2/2014
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