Please take a moment to review Angela’s Good Faith Estimate and Privacy Practices information.

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 health 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 that you 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 or call (800) 985-3059.

Notice of Privacy Practices

1. This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

2. I have the legal duty to safeguard your protected health information (PHI). I am legally required to protect the privacy of your PHI, which includes information that can be used to identify you that I’ve created or received about your past, present or future health or condition, the provision of health care to you, or the payment of this health care, I must provide you with this Notice about my privacy practices, and such Notice must explain how, when and and why I will “use” and “disclose” your PHI> A ‘use” of PHI occurs when I share, examine, utilize, apply or analyze such information within my practice; PHI is “ disclosed” when it is released, transferred, has been give to, or is otherwise divulged to a third party outside of my practice. with some exceptions, I may not use or disclose any more of you PHI than is necessary to accomplish the purpose for which the use or disclosure is made. And, I am legally required to follow the privacy practices described in this Notice.  However, I reserve the right to change the terms of this Notice and my privacy policies at any time. Nay changes will apply to the pHI on file with me already. Before I make any important changes to my policies, I will promptly change this Notice and post a new copy of it in my office and on my website (if applicable). 

3. How I may Use and disclose you PHI. I will use and disclose your PHI for may different reasons. For some of these used or disclosures, I will need you prior authorization; for others, however, I do not. Listed below are the different categories of my uses and disclosures along with some examples of each category.

A. Uses and Disclosures Relating to Treatment, Payment, or Health Care Operations do not require your prior written consent. I can use and disclose you PHI without your consent for the following reasons:

1. For treatment. I can disclose your PHI to physicians, psychiatrists, psychologists, and other licensed care providers who provide you with health care services or are involved in you care. For example, if you’re being treated by a psychiatrist, I can disclose your PHI to you psychiatrist in order to coordinate your care.

2. To obtain payment for treatment. I can use and disclose you PHI to bill and collect payment for the treatment and services provided by me to you. For example, I might send your PHI to your insurance company or health plan to get paid the health care services that I have provided to you. I may also provide you PHI to my business associates, such as billing companies, claims processing companies, and others that process my health care claims.

3. For health care operations. I can disclose your PHI to operate my practice. For example, i might use your PHI to evaluate the quality of health care services that you received or to evaluate the performance of the health care professionals who provided such services to you. May also provide your PHY to our accountants, attorneys, consultants, and others to make sure I am complying with applicable laws.

4. Other disclosures. I may also disclose you PHI to others without your consent in certain situations. For example, you consent is not required if you need emergency treatment, as long as I try to get your consent after treatment is rendered, or if I try to get you consent but you are unable to communicate with me (for example, if you are unconscious or in severe pain) and I think that you would consent to such treatment if you were able to do so.

B. Certain uses and Disclosures that do no require your consent. I can use and disclose your PHI without your consent or authorization for the following reasons:

1. When disclosure is required by federal, state or local law; judicial or administrative proceedings; or, law enforcement. For example, I may make a disclosure to applicable officials when a law requires me to report information to government agencies and law enforcement personnel about victims of abuse or neglect; or when ordered in a judicial or administrative proceeding.

2. For public health activities. I may have to report information about you to the county coroner.

3. For health oversight actives. For example, I may have to provide information to assist the government when it conducts an investigation or inspection of a health care provider or organization.

4. For research purposes. Uncertain circumstances, I may provide PHI in order to conduct medical research.

5. To avoid harm. In order to avoid a serious threat to the PHI to law enforcement personnel or persons able to prevent or lessen such harm.

    6. For specific government functions. I may disclose PHI of military personnel and veterans in certain situations. And I may disclose PHI for national security purposes, such as protecting the President of the United States or conducting intelligence operations.

7. For workers’ compensation purposes. I may provide PHI in order to comply with workers’ compensation laws. 

8. Appointment reminders and health related benefits or services. I may use PHI to provide appointment reminders or give you information about treatment alternatives, or other health care services or benefits I offer.

C. Certain Uses and Disclosures Require You to Have the Opportunity to Object.

1. Disclosures to family, friends, or others. I 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.

D. Other Uses and Disclosures Require Your Prior Written Authorization. In any other situation no described in sections III A, B, and C above, I will ask for your written authorization before using or disclosing any of your PHI. If you choose to sign an authorization to disclose your PHI, you can later revoke such authorization in writing to stop any future uses and disclosures (to the extent that I haven’t taken any action in reliance on such authorization) of you PHI by me.

IV. What rights you have regarding your PHI.

You have the following rights with respect to your PHI:

A. The right to request limits on uses and disclosures of your PHI. You have the right to ask that limit how I use and disclose your PHI. I will consider your request, but I am not legally required to accept it. If I accept your request, I will put any limits in writing and abide by them except in emergency situations. You may not limit the uses and disclosures that I am legally required or allowed to make.

B. The right to choose how I send PHI to you. You have the right to ask that I send information to you to an alternate address (for example, sending information to your work address rather than your home address) or by alternate means (for example, email instead of regular mail). I must agree to your request so long as I can easily provide the PHI to you in the format you requested.

C. The right to see and get copies of your PHI. In most cases, you have the right to look at or get copies of you PHI that I have, but you must make the request in writing. If I don’t have your PHI but I know who does I will tell you how to get it. I will respond to you within 30 days of receiving your written request. In certain situations, I may deny your request. If I do, Iw ill tell you, in writing, my reasons for the denial and explain your right to have my denial reviewed. If you request copies of your PHI, I will charge you you no more that $.25 per page. Instead of providing the PHI you requested, I may provide you with a summary or explanation of the pHI as long as you agree to that and to the cost in advance.

D. The right to get a list of the disclosures I have made. You have the right to get a list of instances in which I have disclosed your PHI. The list will not include uses or disclosures that you have already consented to, such as those made for treatment, payment, or health care operations, directly to you, or to your family. The list also won’t include uses and disclosures made for national security purposes, to corrections or law enforcement personnel. I will respond to your request for an accounting of disclosures within 60 days of receiving your request. The list I will give you will include disclosures made in the last six years unless you request a shorter time.The list will include the date of the disclosure, to whom PHI was disclosed (including either address, if known), a description of the information disclosed, and the reason for the disclosure. I will provide the list to you at no charge, but if you make more than one request in the same year, I will charge you a reasonable cost based fee for each additional request.

E. 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, you have the right to request that I correct the existing information or add the missing information. You must provide the request and your reason for the request in writing. I will respond within 60 days of receiving your request in writing if the pHI is (i) correct and complete, (ii) not created by me, (iii) not allowed to be disclosed, or (iv) not part of my records. My written denial will state the reasons for the denial and explain your right to file a written statement or disagreement with the denial. If you don’t fit one, you have the right to request that your request and my denial be attached to all future disclosures of your PHI. If i approve your request, I will make the change to your PHI, tell you that I have done it, and tell others that need to know about the change to your PHI.

F. The right to get this notice by email. You have to right to get a copy of this notice by email. Even if you have agreed to receive notice via email, you also have the right to request a paper copy of it.

V. How to complain about my privacy practices. If you think that I may have violated your privacy rights, or you disagree with a decision I made about access to your PHI, you may file a complaint with he person listed in Section VI below. You also may send a written complaint to the Secretary of the Department of Health and Human Services at 200 Independence Avenue SW,Washington DC, 20201. I will take no retaliatory action you if you file a complaint about my privacy practices.

VI. Person to contact for information about this notice or to complain about my privacy practices. If you have any questions about this notice or any complaints about my privacy practice, or would like to know how to file a complaint with he Secretary of the Department of Health and Human Services, please contact me at: Angela Wurtzel, LMFT, CEDS-C, PMH-C angela @angelawurtzelmft.com (805) 884-9794

VII. Effective Date of this Notice: November, 25 1997.