Good Faith Estimate

Under the law and in accordance with the Federal No Surprises Act, as of 1/1/2022, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the expected charges for medical items and services.

You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes psychotherapy services.
You can also ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule an item or service.
If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill.
Make sure to save a copy or picture of your Good Faith Estimate.

For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises or call HHS at (800) 368-1019.

Notice of Privacy Practices

This notice describes how health information may be used and disclosed and how you can get access
to this information. Please review it carefully.

I. MY PLEDGE REGARDING HEALTH INFORMATION:
I understand that health information about you and your health care is personal. I am committed to
protecting health information about you. I create a record of the care and services you receive from
me. I need this record to provide you with quality care and to comply with certain legal requirements.
This notice applies to all of the records of your care generated by this mental health care practice.
This notice will tell you about the ways in which I may use and disclose health information about
you. I also describe your rights to the health information I keep about you, and describe certain
obligations I have regarding the use and disclosure of your health information. I am required by law
to:

Make sure that protected health information (“PHI”) that identifies you is kept private.
Give you this notice of my legal duties and privacy practices with respect to health information.
Follow the terms of the notice that is currently in effect.
I can change the terms of this Notice, and such changes will apply to all information I have about you. The new Notice will be available upon request, available in the office, and on my website.

II. HOW I MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU:
The following categories describe different ways that I use and disclose health information. For each
category of uses or disclosures I will explain what I mean and try to give some examples. Not every
use or disclosure in a category will be listed. However, all of the ways I am permitted to use and
disclose information will fall within one of the categories.
For Treatment Payment, or Health Care Operations: Federal privacy rules (regulations) allow health
care providers who have direct treatment relationship with the patient/client to use or disclose the
patient/client’s personal health information without the patient’s written authorization, to carry out
the health care provider’s own treatment, payment or health care operations. I may also disclose your
protected health information for the treatment activities of any health care provider. This too can be
done without your written authorization. For example, if a clinician were to consult with another
licensed health care provider about your condition, we would be permitted to use and disclose your
person health information, which is otherwise confidential, in order to assist the clinician in diagnosis
and treatment of your mental health condition.
Disclosures for treatment purposes are not limited to the minimum necessary standard. Because
therapists and other health care providers need access to the full record and/or full and complete
information in order to provide quality care. The word “treatment” includes, among other things, the
coordination and management of health care providers with a third party, consultations between

health care providers and referrals of a patient for health care from one health care provider to
another.
Lawsuits and Disputes: If you are involved in a lawsuit, I may disclose health information in
response to a court or administrative order. I may also disclose health information about your child in
response to a subpoena, discovery request, or other lawful process by someone else involved in the
dispute, but only if efforts have been made to tell you about the request or to obtain an order
protecting the information requested.

III. CERTAIN USES AND DISCLOSURES REQUIRE YOUR AUTHORIZATION:
1. Psychotherapy Notes. I do keep “psychotherapy notes” as that term is defined in 45 CFR
§ 164.501, and any use or disclosure of such notes requires your Authorization unless
the use or disclosure is:
a. For my use in treating you.
b. For my use in training or supervising mental health practitioners to help them improve
their skills in group, joint, family, or individual counseling or therapy.
c. For my use in defending myself in legal proceedings instituted by you.
d. For use by the Secretary of Health and Human Services to investigate my compliance
with HIPAA.
e. Required by law and the use or disclosure is limited to the requirements of such law.
f. Required by law for certain health oversight activities pertaining to the originator of
the psychotherapy notes.
g. Required by a coroner who is performing duties authorized by law.
h. Required to help avert a serious threat to the health and safety of others.
2. Marketing Purposes. As a psychotherapist, I will not use or disclose your PHI for
marketing purposes.
3. Sale of PHI. As a psychotherapist, I will not sell your PHI in the regular course of my
business.

IV. CERTAIN USES AND DISCLOSURES DO NOT REQUIRE YOUR AUTHORIZATION.
Subject to certain limitations in the law, I can use and disclose your PHI without your Authorization
for the following reasons:
1. When disclosure is required by state or federal law, and the use or disclosure complies
with and is limited to the relevant requirements of such law.
2. For public health activities, including reporting suspected child, elder, or dependent
adult abuse, or preventing or reducing a serious threat to anyone’s health or safety.
3. For health oversight activities, including audits and investigations.
4. For judicial and administrative proceedings, including responding to a court or
administrative order, although my preference is to obtain an Authorization from you
before doing so.
5. For law enforcement purposes, including reporting crimes occurring on my premises.
6. To coroners or medical examiners, when such individuals are performing duties
authorized by law.
7. For research purposes, including studying and comparing the mental health of patients
who received one form of therapy versus those who received another form of therapy for
the same condition.

8. Specialized government functions, including, ensuring the proper execution of military
missions; protecting the President of the United States; conducting intelligence or
counter-intelligence operations; or, helping to ensure the safety of those working within
or housed in correctional institutions.
9. For workers' compensation purposes. Although my preference is to obtain an
Authorization from you, I may provide your PHI in order to comply with workers'
compensation laws.
10. Appointment reminders and health related benefits or services. I may use and disclose
your PHI to contact you to remind you that you have an appointment with me. I may
also use and disclose your PHI to tell you about treatment alternatives, or other health
care services or benefits that I offer.

V. CERTAIN USES AND DISCLOSURES REQUIRE YOU TO HAVE THE OPPORTUNITY TO
OBJECT.
1. Disclosures to family, friends, or others. I may provide your PHI to a family member, friend, or other
person that you indicate is involved in your care or the payment for your health care, unless you
object in whole or in part. The opportunity to consent may be obtained retroactively in emergency
situations.

VI. YOU HAVE THE FOLLOWING RIGHTS WITH RESPECT TO YOUR PHI:
1. The Right to Request Limits on Uses and Disclosures of Your PHI. You have the right
to ask me not to use or disclose certain PHI for treatment, payment, or health care
operations purposes. I am not required to agree to your request, and I may say “no” if I
believe it would affect your health care.
2. The Right to Request Restrictions for Out-of-Pocket Expenses Paid for In Full. You
have the right to request restrictions on disclosures of your PHI to health plans for
payment or health care operations purposes if the PHI pertains solely to a health care
item or a health care service that you have paid for out-of-pocket in full.
3. The Right to Choose How I Send PHI to You. You have the right to ask me to contact
you in a specific way (for example, home or office phone) or to send mail to a different
address, and I will agree to all reasonable requests.
4. The Right to See and Get Copies of Your PHI. Other than “psychotherapy notes,” you
have the right to get an electronic or paper copy of your medical record and other
information that I have about you. I will provide you with a copy of your record, or a
summary of it, if you agree to receive a summary, within 30 days of receiving your
written request, and I may charge a reasonable, cost based fee for doing so.
5. The Right to Get a List of the Disclosures I Have Made.You have the right to request a
list of instances in which I have disclosed your PHI for purposes other than treatment,
payment, or health care operations, or for which you provided me with an Authorization.
I will respond to your request for an accounting of disclosures within 60 days of
receiving your request. The list I will give you will include disclosures made in the last
six years unless you request a shorter time. I will provide the list to you at no charge, but
if you make more than one request in the same year, I will charge you a reasonable cost
based fee for each additional request.
6. The Right to Correct or Update Your PHI. If you believe that there is a mistake in your
PHI, or that a piece of important information is missing from your PHI, you have the
right to request that I correct the existing information or add the missing information. I

may say “no” to your request, but I will tell you why in writing within 60 days of
receiving your request.
7. The Right to Get a Paper or Electronic Copy of this Notice. You have the right get a
paper copy of this Notice, and you have the right to get a copy of this notice by e-mail.
And, even if you have agreed to receive this Notice via e-mail, you also have the right to
request a paper copy of it.