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 certain types of health care coverage or who are not using certain types of health care coverage an estimate of their bill for health care items and services before those items or services are provided.
You have the right to receive a Good Faith Estimate for the total expected cost of any healthcare items or services upon request or when scheduling such items or services.
If you schedule a health care item or service at least 3 business days in advance, make sure your health care provider or facility gives you a Good Faith Estimate in writing within 1 business day after scheduling. If you schedule a healthcare item or service at least 10 business days in advance, make sure your healthcare provider or facility gives you a Good Faith estimate in writing within 3 business days after scheduling. You can also ask any healthcare provider or facility for a Good Faith Estimate before you schedule an item or service. If you do, make sure the health care provider of facility gives you a Good Faith Estimate in writing within 3 business days after you ask.
If you receive a bill that is at least $400 more for any provider or facility than your Good Faith Estimate from that provider or facility, you can dispute the bill.
For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises/consumer, email FederalPPDRQuestions@cms.hhs.gov, or call 1-800-985-3059.
Notice of Privacy Practices
1. OUR COMMITMENT TO PROTECT HEALTH INFORMATION.
We know that information about you and your health care is personal and private, and we are committed to protecting it. We create and maintain records of the care and services you receive to provide quality care and to meet legal requirements. This Notice of Privacy Practices describes our obligations and procedures concerning how we use and disclose any health information about you that is created or maintained by Our Practice.
We are required by law, including the HIPAA Privacy Rule, to:
A. Make sure that protected health information that identifies you (which we call PHI) is kept private, and is used by us or disclosed to others only for a permissible purpose.
B. Give you this Notice stating our legal duties and our procedures relating to PHI, and to follow the terms of the Notice that is currently in effect.
C. Notify affected persons if a breach of unsecured PHI occurs. We may change the policies described in this Notice, and any changes that we make will apply to all of the PHI that we have at the time of the change.
You are receiving an electronic copy of this Notice through the patient portal, but you may request a paper copy of the Notice. Any revision of this Notice will be sent through the patient portal, and paper copies will be provided on request. Any requests and any questions about this Notice should be directed to Stephanie Zerwas, PhD (Owner) who can be reached by email at stephanie@flourishchapelhill.com or by telephone at 984-205-6951.
2. WHEN WE ARE PERMITTED TO USE AND DISCLOSE PHI IN THE ROUTINE COURSE OF PROVIDING SERVICES WITHOUT YOUR APPROVAL FIRST.
In the routine course of providing services to you, Our Practice is permitted by law to USE health information about you within Our Practice, and to DISCLOSE it to others with an appropriate need to have access to it, without getting your approval. This section of the Notice provides some examples of this. Not every use or disclosure in each category is listed, but all of the ways that we use and disclose PHI in the routine course of our services fall within one of the categories of: Treatment, Payment, or Health Care Operations.
Uses and Disclosures for Treatment Payment, or Health Care Operations: Federal and State regulations allow us to USE PHI: (A) To provide diagnosis and treatment for you; and (B) For certain business operations of Our Practice, such as internal quality reviews. Federal and State regulations also allow us to DISCLOSE PHI: (A) to another health care provider who is providing services to you so that provider can furnish their services to you effectively; and (B) to arrange for payment for our services, through a third party such as a private insurance company. But there are important limitations on the use and disclosure of Psychotherapy Notes as noted in Section 3.
3. USES AND DISCLOSURES OF PSYCHOTHERAPY NOTES REQUIRE YOUR PERMISSION FIRST.
Psychotherapy Notes. We keep “Psychotherapy Notes” that contain or analyze the contents of our private counseling sessions. Psychotherapy Notes have more restrictions on their use or disclosure and are kept in a separate part of our records from our records of symptoms, diagnosis, status, treatment plans, progress notes, and prognosis. Without an authorization from you, Psychotherapy Notes may only be used: A) by the person who created them for your treatment; B) by Our Practice to train or supervise mental health professionals to help them improve their counseling session skills; C) by Our Practice to defend itself in any legal action or other proceeding that you might bring.
Any other use or disclosure of Psychotherapy Notes will occur only after you have signed our standard authorization form, in which you specify the portions of the Psychotherapy Notes that may be disclosed, and to whom. Any authorization that you provide for disclosure of Psychotherapy Notes may be revoked by you at any time, and your revocation will be effective at the point when we receive written notice of your revocation.
4. DISCLOSURES OF PHI TO FAMILY AND FRIENDS.
We also may provide PHI, other than Psychotherapy Notes, without getting a separate written authorization from you, to a family member, friend, or other person whom you have identified as being involved in your care, or in the payment for your health care, to the extent that the PHI that we provide to them is directly relevant to any such person’s involvement. In an emergency, we also may disclose limited PHI to a family member, friend, or other person whom you have identified as being involved in your care, if in our judgment, the PHI disclosed is needed to deal with the emergency.
5. PARTICULAR USES AND DISCLOSURES THAT DO NOT REQUIRE YOUR AUTHORIZATION.
Subject to certain limitations in the law, we are permitted to use and disclose PHI that is not contained in the Psychotherapy Notes about our sessions without your Authorization for any of these 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 if we believe that a disclosure is necessary to avoid a serious threat to the health or safety of an individual or of the public.
3. For health oversight by government agencies, including audits and investigations of Our Practice.
4. For judicial and administrative proceedings, including responding to a court or administrative order.
5. For law enforcement purposes, including responses to law enforcement about victims of a crime, reporting crimes occurring at our office, and to coroners or medical examiners, who are performing duties authorized by law.
6. 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.
7. For 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.
8. For workers’ compensation purposes we may provide your PHI in order to comply with workers’ compensation laws.
9. To remind you that you have an appointment or to tell you about treatment alternatives, or other health care services or benefits that we offer.
6. ANY OTHER USE OR DISCLOSURE OF PHI THAT IS NOT DESCRIBED ABOVE CAN ONLY OCCUR WITH YOUR WRITTEN AUTHORIZATION.
For any other situations that are not covered by Sections 1 through 5 of this Notice, we are only permitted to use or disclose PHI after you sign our standard authorization form, in which you specify the PHI that may be disclosed, and to whom. Any authorization that you provide may be revoked by you at any time, effective at the point we receive written notice of your revocation.
7. YOU ALSO HAVE THE FOLLOWING RIGHTS WITH RESPECT TO PHI:
1. The Right to Request Limits on Uses and Disclosures of PHI. You have the right to ask us not to use or disclose certain PHI for the treatment, payment, or health care operations purposes described in Section 2. We are not required to agree to every request, and we may decline if we believe it would adversely affect your health care.
2. The Right to Request Restrictions on Disclosures of PHI for Out-of-Pocket Expenses Paid for by You In Full. You have the right to request, and we will implement, restrictions on disclosures of your PHI to any health insurance plan for payment or health care operations purposes if the PHI pertains solely to an item or a service that you have paid for in full.
3. The Right to Choose How we Send PHI to You. You have the right to ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address, and we will agree to all reasonable requests.
4. The Right to See and Get Copies of 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.
5. 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, or health care operations, or for which you provided us with an Authorization. We will respond to your request for an accounting of disclosures within 60 days of receiving your request. The list we will give you will include disclosures made in the last six years unless you request a shorter time. We will provide the list to you at no charge, but if you make more than one request in the same year, we will charge you a reasonable cost based fee for each additional request.
6. The Right to Correct or Update 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 we correct the existing information or add the missing information. We may say “no” to your request, but we 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 to get a paper copy of this Notice, and you have the right to get a copy of this notice by e-mail. Even if you have agreed to receive this Notice via e-mail, you also have the right to request a paper copy of it.
8. The right to File a Complaint. If you believe that your privacy rights have been violated, you may contact Stephanie Zerwas at stephanie@flourishchapelhill.com or by telephone at 984-205-6951 to file a complaint, and there will be no retaliation if you do so. You also may file a complaint with the U.S. Department of Health and Human Services.