Aly Dearborn, LMFT

Good Faith Estimate

You have the right to receive a “Good Faith Estimate” explaining how much your medical and mental health care will cost. Under the law, health care providers need to give patients who do not have insurance or who are not using insurance, an estimate of the expected charges for medical 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 services. You can ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule a 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.

NOTICE OF PRIVACY PRACTICES

This notice describes how your health information may be used and disclosed, and how you can access it. Please review it carefully.

My Pledge Regarding Your Health Information

I keep a record of the care and services you receive from me to provide quality care and comply with legal and ethical requirements. I am required by law to keep your protected health information (PHI) private, give you this notice of my privacy practices, follow its terms, and notify you of any changes.

How I May Use and Disclose Your Health Information

For treatment, payment, or health care operations — I may use or disclose your PHI without your written authorization to carry out treatment, payment, or operations, including consulting with other providers about your care. Unlike most disclosures, treatment-related disclosures aren’t limited to only the minimum necessary information.

Lawsuits and disputes — I may disclose health information in response to a court order, subpoena, or other lawful process, though I will attempt to notify you first when required.

Uses That Require Your Authorization

Psychotherapy notes — I keep separate psychotherapy notes, which require your written authorization to use or disclose, except when needed for your treatment, for training/supervising other clinicians, to defend myself in a legal proceeding you initiate, for HHS compliance investigations, when required by law, for certain oversight or coroner duties, or to avert a serious safety threat.

Marketing and sale of PHI — I do not use or disclose your PHI for marketing, and I do not sell your PHI.

Uses That Don’t Require Your Authorization

I may use or disclose your PHI without authorization when required by law; for public health and law enforcement purposes (including mandatory abuse reporting or averting a serious threat); for judicial/administrative proceedings; for research; for workers’ compensation; and for appointment reminders or to tell you about treatment alternatives or services.

Your Rights

  • Request restrictions on how your PHI is used or disclosed (I’m not required to agree)
  • Restrict disclosures to insurers for services you’ve paid out-of-pocket in full
  • Choose how I contact you (e.g., preferred phone number or address)
  • Access and copy your record (excluding psychotherapy notes) within 30 days of a written request; a reasonable fee may apply
  • Request an accounting of disclosures made outside of treatment, payment, or operations, within 60 days; a reasonable fee may apply
  • Request corrections to your PHI; I’ll respond in writing within 60 days if I decline
  • Get a paper or electronic copy of this notice at any time

Effective Date: April 20, 2020

Good Faith Estimate

You have the right to receive a “Good Faith Estimate” explaining how much your medical and mental health care will cost. Under the law, health care providers need to give patients who do not have insurance or who are not using insurance, an estimate of the expected charges for medical 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 services. You can ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule a 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.

NOTICE OF PRIVACY PRACTICES

This notice describes how your health information may be used and disclosed, and how you can access it. Please review it carefully.

My Pledge Regarding Your Health Information

I keep a record of the care and services you receive from me to provide quality care and comply with legal and ethical requirements. I am required by law to keep your protected health information (PHI) private, give you this notice of my privacy practices, follow its terms, and notify you of any changes.

How I May Use and Disclose Your Health Information

For treatment, payment, or health care operations — I may use or disclose your PHI without your written authorization to carry out treatment, payment, or operations, including consulting with other providers about your care. Unlike most disclosures, treatment-related disclosures aren’t limited to only the minimum necessary information.

Lawsuits and disputes — I may disclose health information in response to a court order, subpoena, or other lawful process, though I will attempt to notify you first when required.

Uses That Require Your Authorization

Psychotherapy notes — I keep separate psychotherapy notes, which require your written authorization to use or disclose, except when needed for your treatment, for training/supervising other clinicians, to defend myself in a legal proceeding you initiate, for HHS compliance investigations, when required by law, for certain oversight or coroner duties, or to avert a serious safety threat.

Marketing and sale of PHI — I do not use or disclose your PHI for marketing, and I do not sell your PHI.

Uses That Don’t Require Your Authorization

I may use or disclose your PHI without authorization when required by law; for public health and law enforcement purposes (including mandatory abuse reporting or averting a serious threat); for judicial/administrative proceedings; for research; for workers’ compensation; and for appointment reminders or to tell you about treatment alternatives or services.

Your Rights

  • Request restrictions on how your PHI is used or disclosed (I’m not required to agree)
  • Restrict disclosures to insurers for services you’ve paid out-of-pocket in full
  • Choose how I contact you (e.g., preferred phone number or address)
  • Access and copy your record (excluding psychotherapy notes) within 30 days of a written request; a reasonable fee may apply
  • Request an accounting of disclosures made outside of treatment, payment, or operations, within 60 days; a reasonable fee may apply
  • Request corrections to your PHI; I’ll respond in writing within 60 days if I decline
  • Get a paper or electronic copy of this notice at any time

Effective Date: April 20, 2020