EFFECTIVE DATE OF THIS NOTICE
This notice went into effect on [August 20th, 2021]
NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW HEALTH INFORMATION MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
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:
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 personal 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:
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:
V. CERTAIN USES AND DISCLOSURES REQUIRE YOU TO HAVE THE OPPORTUNITY TO OBJECT.
VI. YOU HAVE THE FOLLOWING RIGHTS WITH RESPECT TO YOUR PHI:
Effective January 1st, 2022, I am required to post about a new law that broadly applies to all licensed healthcare providers. This is called a “Good Faith Estimate”.
In general, to calculate your estimated out of pocket cost of therapy for cash pay/uninsured clients--(Session fee) X (Number of sessions in 12 month period) = Total estimated cost of therapy services (weekly attendance).
This number does not include fess for no shows or late cancellations (less than 24 hours notice). As a clinician, it is not possible or ethical for me to diagnose or accurately estimate the length of time for therapeutic treatment prior to meeting with you, so the above 12 month period is an estimate. Together, we will collaborate on your treatment plan; this will be reviewed and updated every ninety days. Please note that a Good Faith Estimate does not require you to obtain any service from me or any other health care provider, and you are able to cancel services at any time, should you wish.
Under the law, health care providers need to give clients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services.
My fee schedule is as follows:
$180 for comprehensive individual mental health assessment (60 minute)
$200 for couple’s assessment (60 minute)
$148+/session for ongoing therapeutic work depending on length of appointment (50 minute versus 80 minute)
$160+/EMDR session, depending on length of appointment (50 minute versus 80 minute)
You can expect between 3-12 months of mental health treatment, at the frequency of 2-4 sessions per month, depending on your current needs.
For questions or more information about your right to a GFE, visit www.cms.gov/nosurprises
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