Notice of Good Faith Estimate and Privacy Practices

Your Right to a Good Faith Estimate

You have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost.

Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of expected charges for medical and administrative services, including psychotherapy services.

You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency healthcare services, including psychotherapy.
Make sure your therapist gives you a Good Faith Estimate in writing before your scheduled service or upon request.
If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill.
For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises or call (800) 985-3059.

Notice of Privacy Practices

EFFECTIVE DATE OF THIS NOTICE: This notice went into effect on June 1, 2021, and was reviewed on May 1, 2026.

NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION MAY BE USED AND DISCLOSED AND HOW YOU CAN ACCESS THIS INFORMATION. PLEASE REVIEW IT CAREFULLY AND SIGN AND DATE BELOW TO ACKNOWLEDGE RECEIPT.

I. OUR PLEDGE REGARDING HEALTH INFORMATION:

We understand that health information about you and your health care is personal. We are committed to protecting your health information. We create a record of the care and services you receive from us. We 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 practice, including psychotherapy services and neurodevelopmental assessments.

This notice explains how we may use and disclose health information about you. We also describe your rights to the health information we keep about you and our obligations regarding the use and disclosure of your health information. We are required by law to:

Ensure that protected health information (PHI) that identifies you is kept confidential and private.
Provide you with this notice of our legal duties and privacy practices concerning health information.
Follow the terms of the Notice that is currently in effect.
We reserve the right to modify the terms of this Notice, and such modifications will apply to all information we have about you. The new Notice will be available in our office and in Simple Practice upon request.

II. HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU:

The following categories describe different ways that we use and disclose health information. For each category of use or disclosure, we will explain what we mean and provide some examples. Not every use or disclosure in a category will be listed. However, all the ways we are permitted to use and disclose information will fall within one of the categories.

For Treatment and Related Services Payment or Health Care Operations: Federal privacy rules (regulations) allow healthcare providers who have a 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 healthcare provider’s treatment and related services, and payment or health care operations. For example, contacting a patient or client’s family to secure payment or update expired credit cards. We may also disclose your protected health information for the treatment activities of any healthcare provider. This, too, can be done without your written authorization. For example, if a clinician were to consult with another licensed healthcare provider about your condition, we would be permitted to use and disclose your personal health information, which is otherwise confidential, to assist the clinician in diagnosing and treating your mental health condition.

Disclosures for treatment and related services purposes are not limited to the minimum necessary standard, because therapists and other healthcare providers need access to the full record and/or complete information to provide quality care. The word “treatment” includes, among other things, the coordination and management of healthcare providers with a third party, consultations between healthcare providers, and patient referrals for healthcare from one healthcare provider to another.

Lawsuits and Disputes: If you are involved in a lawsuit, we may disclose health information in response to a court or administrative order. We 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:

Psychotherapy Notes. We 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:

For our use in treating you.
For our use in training or supervising mental health practitioners to enhance their skills in group, joint, family, or individual counseling or therapy.
This is for our use in defending ourselves in legal proceedings instituted by you.
This is for use by the Secretary of Health and Human Services to investigate our compliance with HIPAA.
Required by law, and the use or disclosure is limited to the requirements of such law.
Required by law for certain health oversight activities pertaining to the originator of the psychotherapy notes.
Required by a coroner who is performing duties authorized by law.
Required to help avert a serious threat to the health and safety of others.

*Please note that neurodevelopmental assessment records are maintained separately from psychotherapy notes and are not classified as psychotherapy notes under HIPAA. These records are part of your general medical record and are subject to the standard PHI protections described in this notice.

Marketing Purposes. As a behavioral health practice, we will not use or disclose your PHI for marketing purposes and will not sell your PHI in the regular course of our business.

IV. CERTAIN USES AND DISCLOSURES REQUIRE YOU TO HAVE THE OPPORTUNITY TO OBJECT.

Disclosures to family, friends, or others. We may provide your PHI to a family member, friend, or another person 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 emergencies.

V. YOU HAVE THE FOLLOWING RIGHTS CONCERNING YOUR PHI:

The Right to Request Limits on Uses and Disclosures of Your PHI. You have the right to request that we not use or disclose certain protected health information (PHI) for treatment, payment, or health care operations. We are not required to agree to your request and may decline it if it impacts your healthcare.
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 service you have paid for out-of-pocket in full.
The Right to Choose How We Send PHI to You. You have the right to request that we contact you in a specific manner (for example, by home or office phone) or to send mail to a different address, and we will accommodate all reasonable requests.
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 we have about you. We 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 we may charge a reasonable, cost-based fee for doing so.
The Right to Get a List of the Disclosures We Have Made. You have the right to request a list of instances in which we have disclosed your PHI for purposes other than treatment, payment, healthcare operations, or for which you provided us with authorization. We will respond to your request for an accounting of disclosures within 60 days of receipt. Our list will include disclosures made within the last six years, unless you request a shorter timeframe. We will provide the list to you at no charge. However, if you make more than one request in the same year, we will charge a reasonable, cost-based fee for each additional request.
The Right to Correct or Update Your PHI. If you believe that your PHI contains a mistake or that important information is missing, you have the right to request that we correct the existing information or add the missing information. We may decline your request, but we will provide a written explanation within 60 days of receiving it.
The Right to Get a Paper or Electronic Copy of this Notice. You have the right to 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.

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