GOOD FAITH ESTIMATE/No Surprises Act
STANDARD NOTICE
“Right to Receive a Good Faith Estimate of Expected Charges”
Under the No Surprises Act
Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services.
1. You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees.
2. Make sure your health care provider gives you a Good Faith Estimate in writing at least one business day before your medical service or item. You can also ask your health care provider, and any other provider you choose for a Good Faith Estimate before you schedule an item or service.
3. If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill.
4. 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 or call 512-522-1061
Privacy Policy
NOTICE OF PRIVACY PRACTICES
Clover and Bloom Counseling PLLC follows a strict privacy policy and cares about protecting your privacy.
The following notice explains how Clover and Bloom Counseling PLLC protects your Personal Health Information (PHI), how Clover and Bloom Counseling PLLC may use or disclose your health information, details of your privacy rights, and how you can gain access to it.
We will discuss this in our first meeting during the informed consent process. Please read it carefully prior to our first meeting and share any questions you have about it so we can discuss them together.
PRIVACY PRACTICES
How Clover and Bloom Counseling PLLC Uses and Discloses Your Information
- Victims of Abuse, Neglect, or Domestic Violence- If Clover and Bloom Counseling PLLC has reason to believe that believe that you, a child or elderly person are victims of abuse, neglect, or domestic violence, the clinician may disclose health information about you or your child to a governmental agency that requires such reports as mandated by Texas law.
- Serious Threat to Health or Safety- Clover and Bloom Counseling PLLC may use or disclose health information about you or your child if the clinician believes the use or disclosure is needed to prevent a serious and immediate threat to the health and safety of yourself, a person or the public.
- In Judicial Proceedings- Clover and Bloom Counseling PLLC may disclose your or your child’s health information in any criminal or civil proceeding if a court or judge has issued a court order or subpoena that requires us to disclose it.
Privacy and Security Policies
Measures have been taken to ensure confidentiality of emails/texts sent and received but, these forms of communication are not encrypted and personal health information (PHI) is recommended to only be sent through the HIPPA compliant and secure patient portal . Email or text is best used for scheduling purposes only. At your own risk, you can choose to opt-in to electronic communication by signing an authorization form provided by Clover and Bloom Counseling PLLC. Please be aware of the risks taken when sharing personal information this way:
- Mis-delivery of email/text to an incorrectly typed address or number.
- Email accounts can be "hacked", giving a 3rd party access to email content and addresses.
- Email/texts messaging providers can keep a copy of each email/text on their servers, where it might be accessible to employees, etc.
- If there is a breach regarding your PHI, Clover and Bloom Counseling PLLC will contact you to let you know the extent of the breach and what is being done to contain the situation.
- Clover and Bloom Counseling PLLC does not use any of your PHI for marketing purposes and does not sell any information to outside entities.
- Clover and Bloom Counseling PLLC follows all Ethical Codes and State Laws, which help in securing your information.
- All HIPAA documentation will be kept on file for a minimum of 7 years.
Storage of Client Files:
- Clover and Bloom Counseling PLLC stores client files securely and confidentially for 7 years after the last session.
- If something should happen to your clinician, a designated counselor, listed in the Informed Consent for Counseling Services, would take possession of these files and follow the same confidentiality protocols.
- Once a file is ready to be destroyed, any paper copies will be shredded and electronic files will be permanently deleted from any storage.
CLIENT PRIVACY
Private Health Information may be used and disclosed in the following circumstances:
- Information that is necessary in order to file insurance claims and successfully complete all billing and collection procedures.
- When required for public health issues such as workman's compensation.
- When required by any state or federal law, including cases of abuse and neglect.
- When required for any specialized government or military functions including active personnel, reservists, veterans, and discharged members of the military service. Also, for any person confined to a correctional institution or under any law enforcement supervision.
- When used for any clerical purposes and necessary chart audits by managed care companies.
- Excluding the circumstances listed above, Clover and Bloom Counseling PLLC will not release any information without your written permission.
As a client, you have rights to your Private Health Information, including:
- The right to review your records, receive a copy of your records, or amend your records by signing and sending a written request via mail or electronically. However, under certain circumstances your request can be denied. Clover and Bloom Counseling PLLC will inform you in writing if the request is denied. In case of denial of copy of your records, you may choose to receive a summary of progress instead. The summary includes information about symptoms and treatment plans/goals. Requests by text message will not be accepted.
- Requests for records will receive a response within 15 days.
- The right to request information of disclosures made by Clover and Bloom Counseling PLLC to any party that has requested information pertaining to your PHI.
- The right to receive confidential information regarding your PHI.
- The right to revoke this consent in writing; however, this will not affect any information already disclosed.
- Request a copy of this notice at any time.
If you as the client feel your privacy has been violated, you have the right to contact The U.S. Department of Health & Human Services Office of Civil Rights at www.hhs.gov/ocr/hipaa/ or The Office of the Attorney General at https://www.texasattorneygeneral.gov/cpd/state-and-federal-health-privacy-laws.
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