Consent Form
About PSYCKES
The New York State (NYS) Office of Mental Health maintains the Psychiatric Services and Clinical Knowledge Enhancement System (PSYCKES). This online database stores some of your medical history and other information about your health. It can help your health providers deliver the right care when you need it.
The information in PSYCKES comes from your medical records, the NYS Medicaid database and other sources. Go to www.psyckes.org, and click on About PSYCKES to learn more about the program and where your data comes from.
This data includes:
- Your name, date of birth, address and other information that identifies you;
- Your health services paid for by Medicaid;
- Your health care history, such as illnesses or injuries treated, test results and medicines;
- Other information you or your health providers enter into the system, such as a health Safety Plan.
What You Need to Do
Your information is confidential, meaning others need permission to see it. Complete this form now or at any time if you want to give or deny your providers access to your records. What you choose will not affect your right to medical care or health insurance coverage.
Please read the back of this page carefully before checking one of the boxes below. Choose:
- I GIVE CONSENT if you want this provider, and their staff involved in your care, to see your PSYCKES information.
- I DON’T GIVE CONSENT if you don’t want them to see it.
If you don’t give consent, there are some times when this provider may be able to see your health information in PSYCKES – or get it from another provider – when state and federal 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. 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 Page 1/2 referred to as “HIPAA”).
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 Page 1/2 referred to as “HIPAA”).
