Documentation and Forms

As a patient, you have the right to be informed about the expected costs of your medical and mental health care. Under the law, health care providers are required to provide patients who do not have insurance or who are not using insurance with a Good Faith 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 request a Good Faith Estimate from your healthcare provider or any other provider you choose before scheduling a service. 

If you receive a bill that is at least $400 more than your Good Faith Estimate, you have the right to dispute the bill. It is essential to save a copy or picture of your Good Faith Estimate for future reference. 

For more information about your right to a Good Faith Estimate, please visit www.cms.gov/nosurprises. We encourage all patients to be informed about their rights and responsibilities when it comes to healthcare costs, and we are committed to providing transparency and clarity in our billing practices. 

EFFECTIVE DATE OF THIS NOTICE This notice went into effect on April 17, 2023

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. PLEDGE REGARDING HEALTH INFORMATION: Health information about you and your health care is personal. Fresh Sands Counseling & Consulting Services is committed to protecting health information about you. We will create a record of the care and services you receive, which is need 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 we may use and disclose health information about you. It also describes your rights to the health information and describes certain obligations regarding the use and disclosure of your health information. Fresh Sands Counseling & Consulting Services is required by law to:

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

II. HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED: The following categories describe different ways that Fresh Sands Counseling & Consulting Services may use and disclose health information.

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, Fresh Sands Counseling & Consulting Services may disclose health information in response to a court or administrative order. Health information about your child may also be disclosed 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. Fresh Sands Counseling & Consulting Services keeps “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 use in treating you. b. For 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 use in defense of legal proceedings instituted by you. d. For use by the Secretary of Health and Human Services to investigate 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, Fresh Sands Counseling & Consulting Services will not use or disclose your PHI for marketing purposes.
3. Sale of PHI. As a psychotherapist, Fresh Sands Counseling & Consulting Services will not sell your PHI in the regular course of business.

IV. CERTAIN USES AND DISCLOSURES DO NOT REQUIRE YOUR AUTHORIZATION. Subject to certain limitations in the law, Fresh Sands Counseling & Consulting Services 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 the 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 the preference is to obtain an Authorization from you, Fresh Sands Counseling & Consulting Services may provide your PHI in order to comply with workers’ compensation laws.
10. Appointment reminders and health related benefits or services. Fresh Sands Counseling & Consulting Services may use and disclose your PHI to contact you to remind you that you have an appointment with me. We 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. Fresh Sands Counseling & Consulting Services 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 your provider not to use or disclose certain PHI for treatment, payment, or health care operations purposes. Fresh Sands Counseling & Consulting Services is not required to agree to your request, and may say “no” if it is believed it would negatively 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 PHI is sent 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 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 your provider has about you. Fresh Sands Counseling & Consulting Services 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 Made. You have the right to request a list of instances in which Fresh Sands Counseling & Consulting Services have disclosed your PHI for purposes other than treatment, payment, or health care operations, or for which you provided me with an Authorization. Fresh Sands Counseling & Consulting Services will respond to your request for an accounting of disclosures within 60 days of receiving your request. The list 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, you may be charged 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. we may say “no” to your request, but 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.