PRACTICE POLICIES (CONSENT FOR SERVICES + NOTICE OF PRIVACY PRACTICES +

NOTICE OF INDIVIDUAL’S RIGHT TO RECEIVE A GOOD FAITH ESTIMATE)

CONSENT FOR SERVICES

Horizons Holistic Healing, PLLC

2310 N Henderson Ave #1415

Dallas, TX 75206

www.horizonsholistichealing.com

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This form is called a Consent for Services (the "Consent"). Your therapist, counselor, psychologist,

doctor, or other health professional ("Provider") has asked you to read and sign this Consent before

you start therapy. Please review the information. If you have any questions, contact your Provider.

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THE THERAPY PROCESS

Therapy is a collaborative process where you and your Provider will work together on equal footing

to achieve goals that you define. This means that you will follow a defined process supported by

scientific evidence, where you and your Provider have specific rights and responsibilities. Therapy

generally shows positive outcomes for individuals who follow the process. Better outcomes are often

associated with a good relationship between a client and their Provider. To foster the best possible

relationship, it is important you understand as much about the process before deciding to commit.

Therapy begins with the intake process. First, you will review your Provider's policies and

procedures, talk about fees, identify emergency contacts, and decide if you want health insurance to

pay your fees depending on your plan's benefits. Second, you will discuss what to expect during

therapy, including the type of therapy, the length of treatment, and the risks and benefits. If your

Provider is practicing under the supervision of another professional, your Provider will tell you about

their supervision and the name of the supervising professional. Third, you will form a treatment plan,

including the type of therapy, how often you will attend therapy, your short- and long-term goals, and

the steps you will take to achieve them. Over time, you and your Provider may edit your treatment

plan to be sure it describes your goals and steps you need to take. After intake, you will attend

regular therapy sessions at your Provider's office or through video, called telehealth. Participation in

therapy is voluntary - you can stop at any time. At some point, you will achieve your goals. At this

time, you will review your progress, identify supports that will help you maintain your progress, and

discuss how to return to therapy if you need it in the future.

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Services Provided:

Clinicians at Horizons Holistic Healing may offer individual, couple, family, intensive, and/or group

therapy services. Each session is approximately 53 minutes and sessions typically occur at least

once per week, unless otherwise agreed. Sessions may sometimes be longer or more frequent, as

agreed between you and your clinician. Your clinician does not provide emergency or crisis

interventions and is not available 24 hours per day; however, you can always leave a message on

his/her voicemail or email and your clinician will contact you as soon as possible. In the event of an

emergency or crisis between scheduled appointments, go to the nearest emergency room or call 911

if it is a life-threatening situation. Your initial sessions include an evaluation of current concerns and

needs and are therefore devoted to gathering information about you, your current difficulties, and

biographical information that will assist your clinician in developing a treatment plan andinterventions that are specific to you. The initial evaluation typically lasts from two to four sessions.

Participation in therapy is voluntary - you can stop at any time. At some point, you will achieve your

goals. At this time, you will review your progress, identify supports that will help you maintain your

progress, and discuss how to return to therapy if you need it in the future.

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Intake Sessions (First Session):

For new patients, if all intake paperwork is not received and completed at least 24 hours before your

scheduled intake session, your intake session may be cancelled and you may receive an email to

reschedule. Clinicians require some time to look over initial paperwork before the first session to

address any initial concerns they may have and to help create a treatment plan. Completing your

paperwork on time also signals a commitment to the therapy process and taking seriously this first

step.

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IN-PERSON VISITS & SARS-CoV-2 ("COVID-19")

(Horizons Holistic Healing is currently a fully virtual practice)

When guidance from public health authorities allows and your Provider offers, you can meet

in-person. If you attend therapy in-person, you understand:

• You can only attend if you are symptom-free (For symptoms, see:

https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html);

• If you are experiencing symptoms, you can switch to a telehealth appointment or cancel. If you

need to cancel, you will not be charged a late cancellation fee.

• You must follow all safety protocols established by the practice, including:

• Following the check-in procedure;

• Washing or sanitizing your hands upon entering the practice;

• Adhering to appropriate social distancing measures;

• Wearing a mask, if required;

• Telling your Provider if you have a high risk of exposure to COVID-19, such as through school,

work, or commuting; and

• Telling your Provider if you or someone in your home tests positive for COVID-19.

• Your Provider may be mandated to report to public health authorities if you have been in the office

and have tested positive for infection. If so, your Provider may make the report without your

permission, but will only share necessary information. Your Provider will never share details about

your visit. Because the COVID-19 pandemic is ongoing, your ability to meet in person could change

with minimal or no notice. By signing this Consent, you understand that you could be exposed to

COVID-19 if you attend in-person sessions. If a member of the practice tests positive for COVID-19,

you will be notified. If you have any questions, or if you want a copy of this policy, please ask.

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TELEHEALTH SERVICES

To use telehealth, you need an internet connection and a device with a camera for video. Your

Provider can explain how to log in and use any features on the telehealth platform. If telehealth is not

a good fit for you, your Provider will recommend a different option. There are some risks and benefits

to using telehealth:

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Risks

• Privacy and Confidentiality. You may be asked to share personal information with the telehealth

platform to create an account, such as your name, date of birth, location, and contact information.Your Provider carefully vets any telehealth platform to ensure your information is secured to the

appropriate standards.

• Technology. At times, you could have problems with your internet, video, or sound. If you have

issues during a session, your Provider will follow the backup plan that you agree to prior to sessions.

• Crisis Management. It may be difficult for your Provider to provide immediate support during an

emergency or crisis. You and your Provider will develop a plan for emergencies or crises, such as

choosing a local emergency contact, creating a communication plan, and making a list of local

support, emergency, and crisis services.

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Benefits

• Flexibility. You can attend therapy wherever is convenient for you. However, you may not be in a

moving vehicle due to safety concerns.

• Ease of Access. You can attend telehealth sessions without worrying about traveling, meaning you

can schedule less time per session and can attend therapy during inclement weather or illness.

Recommendations

Prior to starting video-conferencing services, we discussed and agreed to the following:

• There are potential benefits and risks of video-conferencing (e.g. limits to patient confidentiality)

that differ from in-person sessions.

• Confidentiality still applies for telehealth services, and nobody will record the session without the

permission from the others person(s).

• We agree to use the video-conferencing platform selected for our virtual sessions, and the clinician

will explain how to use it.

• You need to use a webcam or smartphone during the session.

• It is important to be in a quiet, private space that is free of distractions (including cell phone or other

devices) during the session.

• It is important to use a secure internet connection rather than public/free Wi-Fi.

• It is important to be on time. If you need to cancel or change your tele-appointment, you must notify

the clinician in advance by phone or email. Cancellations of less than 48 hours notice will incur a fee

(after one free no show/late cancellation per year) equivalent to the session fee. If you are able to

reschedule within the same week and there is availability, this is another option instead of the fee.

• We need a back-up plan (e.g., phone number where you can be reached) to restart the session or

to reschedule it, in the event of technical problems.

• We need a safety plan that includes at least one emergency contact and the closest ER to your

location, in the event of a crisis situation.

• If you are not an adult, we need the permission of your parent or legal guardian (and their contact

information) for you to participate in telepsychology sessions.

• If you are wanting to use your superbill to get reimbursed, you should confirm with your insurance

company that the video sessions will be reimbursed; if they are not reimbursed, you are still

responsible for full payment.

• Your clinician may determine that due to certain circumstances, telehealth is no longer appropriate

and that you may benefit from in-person sessions.

• Make sure that other people cannot hear your conversation or see your screen during sessions.

• Make sure to let your Provider know if you are not in your usual location before starting any

telehealth session.

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CONFIDENTIALITY

In keeping with professional ethical standards and state and federal law, all services provided by

your clinician are kept confidential except as noted below and in the accompanying Notice of Privacy

Practices. As required by licensed professional counselor practice guidelines and current standards

of care, your clinician keeps records of all therapy sessions. These records are stored securely

consistent with federal and professional security standards for medical records. Your clinician has a

legal responsibility to disclose client information without prior consent when a client is likely to harm

himself/herself or others unless protective measures are taken, when there is reasonable suspicion

of abuse of children, dependent adults or the elderly, when the client lacks the capacity to care for

him or herself and when there is a valid court order for the disclosure of client files. By signing the

consent form, you also give your clinician permission to communicate with the Emergency Contact

that you have designated if he/she believes that you are at risk. If you are suing someone or being

sued, or if you are charged with a crime and you tell the court that you are a client of your clinician’s,

and your clinician may then be ordered to show the court your records. Please consult your lawyer

about these issues. Please consult with your clinician if you have any questions about confidentiality.

Please see Insurance Reimbursement section regarding some confidentiality issues associated with

using your insurance benefits.

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Your Provider will not disclose your personal information without your permission unless required by

law. If your Provider must disclose your personal information without your permission, your Provider

will only disclose the minimum necessary to satisfy the obligation. However, there are a few

exceptions.

• Your Provider may speak to other healthcare providers involved in your care.

• Your Provider may speak to emergency personnel.

• If you report that another healthcare provider is engaging in inappropriate behavior, your Provider

may be required to report this information to the appropriate licensing board. Your Provider will

discuss making this report with you first, and will only share the minimum information needed while

making a report. If your Provider must share your personal information without getting your

permission first, they will only share the minimum information needed. There are a few times that

your Provider may not keep your personal information confidential.

• If your Provider believes there is a specific, credible threat of harm to someone else, they may be

required by law or may make their own decision about whether to warn the other person and notify

law enforcement. The term specific, credible threat is defined by state law. Your Provider can explain

more if you have questions.

• If your Provider has reason to believe a minor or elderly individual is a victim of abuse or neglect,

they are required by law to contact the appropriate authorities.

• If your Provider believes that you are at imminent risk of harming yourself, they may contact law

enforcement or other crisis services. However, before contacting emergency or crisis services, your

Provider will work with you to discuss other options to keep you safe.

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RECORD KEEPING

Your Provider is required to keep records about your treatment. These records help ensure the

quality and continuity of your care, as well as provide evidence that the services you receive meet

the appropriate standards of care. Your records are maintained in an electronic health record

provided by TherapyNotes. TherapyNotes has several safety features to protect your personalinformation, including advanced encryption techniques to make your personal information difficult to

decode, firewalls to prevent unauthorized access, and a team of professionals monitoring the system

for suspicious activity. TherapyNotes keeps records of all log-ins and actions within the system.

Horizons Holistic Healing, PLLC will retain custody and control of the client's mental health records

in the event of the licensee's death or incapacity, or the termination of the licensee's counseling

practice.

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COMMUNICATION

Contacting Clinicians: Due to your clinician’s work schedule, he/she is often not immediately

available by telephone. When he/she is not available, you may leave a message on his/her

confidential voicemail or email and every effort will be made to return your message within 48 hours,

except for weekends and holidays. If you are difficult to reach, please inform your clinician of times

you might be available. Please be aware that e-mail may not be private or confidential and may not

be read by the recipient in a timely fashion. You can reach out to your clinician via the Horizons

Holistic Healing website and the Patient Portal via Therapy Notes as well. In the case of an

emergency, please call 911, your family physician, or go to the nearest emergency room and ask for

the psychologist, counselor, or psychiatrist on call.

You decide how to communicate with your Provider outside of your sessions. You have several

options:

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Texting/Email

• Texting and email are not secure methods of communication and should not be used to

communicate personal information. You may choose to receive appointment reminders via text

message or email. You should carefully consider who may have access to your text messages or

emails before choosing to communicate via either method.

Secure Communication

• Secure communications are the best way to communicate personal information, though no method

is entirely without risk. Your Provider will discuss options available to you. If you decide to be

contacted via non-secure methods, your Provider will document this in your record.

Social Media/Review Websites

• If you try to communicate with your Provider via these methods, they will not respond. This includes

any form of friend or contact request, @mention, direct message, wall post, and so on. This is to

protect your confidentiality and ensure appropriate boundaries in therapy.

• Your provider may publish content on various social media websites or blogs. There is no

expectation that you will follow, comment on, or otherwise engage with any content. If you do choose

to follow your Provider on any platform, they will not follow you back.

• If you see your Provider on any form of review website, it is not a solicitation for a review. Many

such sites scrape business listings and may automatically include your Provider. If you choose to

leave a review of your Provider on any website, they will not respond. While you are always free to

express yourself in the manner you choose, please be aware of the potential impact on your

confidentiality prior to leaving a review. It is often impossible to remove reviews later, and some sites

aggregate reviews from several platforms leading to your review appearing other places without your

knowledge.FEES AND PAYMENT FOR SERVICES

You may be required to pay for services and other fees. You will be provided with these costs prior to

beginning therapy, and should confirm with your insurance if part or all of these fees may be

covered. You should also know about the following:

No-Show, Rescheduling, and Late Cancellation Fees

• Horizons Holistic Healing charges your full-fee amount for no-show, failed reschedule attempts,

and late cancellations (any cancellations without 48 hours notice).

• If you let me know at least 48 hrs before that you would like to reschedule, and we confirm we are

able to reschedule within the same week, no fee will be charged - if unsure, have a quickly

changing schedule, or unable to reschedule in same week, go ahead and cancel for certain 48

hrs before and then re-book if needed to avoid fee.

• If you confirm your reschedule date and then cancel the rescheduled appt at any time before then,

you will be charged your full fee. Rescheduled appointments also cannot be rescheduled.

• If you are unable to attend therapy, you must contact your Provider before your session. Otherwise,

you may subject to fees outlined in your fee agreement. Insurance does not cover these fees.

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Balance Accrual

• Full payment is due at the time of your session. If you are unable to pay, tell your Provider. Your

Provider may offer payment plans or a sliding scale. If not, your Provider may refer you to other low-

or no-cost services. Any balance due will continue to be due until paid in full. If necessary, your

balance may be sent to a collections service.

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Administrative Fees

• Your Provider may charge administrative fees for preparation of requesting a copy of records;

writing a letter or report at your request; consulting with another healthcare provider or other

professional outside of normal case management practices; or for preparation, travel, and

attendance at a court appearance. These fees are listed further down in this agreement. Payment is

due in advance.

OON Insurance Benefits (for Superbills)

• Before starting therapy, if you are wanting to use your OON benefits, you should confirm with your

insurance company if:

• You have OON benefits + when those kick in

• Your benefits cover the type of therapy you will receive;

• Your benefits cover in person and/or telehealth sessions;

• You may be responsible for any portion of the payment; and

• Your Provider is in-network or out-of-network.

Sharing Information with Insurance Companies

• If you choose to use insurance benefits to get reimbursed for services, you will be required to share

personal information with your insurance company. Insurance companies keep personal information

confidential unless they must share to act on your behalf, comply with federal or state law, or

complete administrative work.

Covered and Non-Covered Services

• When your Provider is in-network, they have a contract with your insurance company. Yourinsurance plan may cover all or part of the cost of therapy. You are responsible for any part of this

cost not covered by insurance, such as deductibles, copays, or coinsurance. You may also be

responsible for any services not covered by your insurance.

• When your Provider is out-of-network, they do not have a contract with your insurance company.

You can still choose to see your Provider; however, all fees will be due at the time of your session to

your Provider. Your Provider will tell you if they can help you file for reimbursement from your

insurance company. If your insurance company decides that they will not reimburse you, you are still

responsible for the full amount. (Horizons Holistic Healing is an out-of-network Provider but can

provide superbills upon request. We are also partnered with Mentaya for more streamlined OON

reimbursement-see further below)

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What is a Superbill?

A superbill is a detailed receipt that clinicians can provide (upon request) after sessions each month.

If you have out-of-network benefits on your insurance plan, a superbill can help you get reimbursed

for some of the costs.It includes:

Clinician's name and credentials

Your name and date of service

The type of therapy you received

The session fee

Relevant diagnostic codes

Here’s how it works:

1. 2. 3. Check Your Insurance Plan: Look at your policy to see if you have out-of-network benefits.

This usually means you can still get some coverage, even if clinician is not in-network with

your insurance.

Use the Superbill for Reimbursement: Upon request, at the end of the month, your clinician

can provide you with a superbill including all your sessions for that month. You can submit

this to your insurance company to request reimbursement for the fees you’ve paid.

Reimbursement Amount: The amount you get back depends on your specific plan. Some

plans cover a percentage of the session fee, while others may have a deductible that you

need to meet first.

Steps to Submit a Superbill:

1. 2. Keep the Superbill: At the end of each month, your clinician will provide you with a superbill.

Submit to Insurance: Follow your insurance company’s submission guidelines. This often

involves filling out a claim form and attaching the superbill.

3. Follow Up: You may need to follow up with your insurance to ensure the claim is processed

correctly.

4. Expected Timeframe for Reimbursement:

Typically, it can take 2 to 6 weeks for your insurance company to process your

claim and issue a reimbursement.

If there are any issues or additional information required, it may take longer. It’s a

good idea to follow up with your insurance provider if you haven’t received

reimbursement within this timeframe.Mentaya for OON Reimbursement

At Horizons, we've partnered with Mentaya to simplify insurance reimbursement for our clients.

Here's what you need to know:

1. 2. 3. 4. Mentaya's Role: We utilize Mentaya to explore reimbursement possibilities for your

out-of-network therapy sessions. They handle claims and insurance paperwork to assist you

in getting reimbursed.

Reimbursement Process: If eligible, Mentaya will manage your claims for a 5% fee per

claim.

Optional Participation: Using Mentaya for reimbursement is entirely optional, and it won't

affect your therapy service quality or availability.

Therapist Neutrality: I, as your therapist, do not benefit from your choice to use Mentaya.

My goal is to support your well-being.

Consent to Release of Information:

By signing this informed consent of services, you acknowledge that (if you choose to use Mentaya)

Mentaya will have access to your full name, date of birth, and diagnosis to submit claims on your

behalf.

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Payment Methods

• The practice requires that you keep a valid credit or debit card on file. This card will be charged for

the amount due at the time of service and for any fees you may accrue unless other arrangements

have been made with the practice ahead of time. It is your responsibility to keep this information up

to date, including providing new information if the card information changes or the account has

insufficient funds to cover these charges.

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Additional Costs:

Late Cancellation/Rescheduling/No Show Fees –

• Horizons Holistic Healing charges your full-fee amount for no-show, failed reschedule attempts,

and late cancellations (any cancellations without 48 hours notice).

• If you miss or cancel an appointment without providing 48 hours’ notice and are unable to

reschedule within the same week, you, not your insurance company, will be required to pay the

cancellation fee at time of original schedule appointment. Repeated cancellations or missed

appointments may result in the termination of services.

• If you let me know at least 48 hrs before that you would like to reschedule, and we confirm we are

able to reschedule within the same week, no fee will be charged - if unsure, have a quickly

changing schedule, or unable to reschedule in same week, go ahead and cancel for certain 48

hrs before and then re-book if needed to avoid fee.

• If you confirm your reschedule date and then cancel the rescheduled appt at any time before then,

you will be charged your full fee. Rescheduled appointments also cannot be rescheduled.

• If you are unable to attend therapy, you must contact your Provider before your session. Otherwise,

you may subject to fees outlined in your fee agreement. Insurance does not cover these fees.

Professional Fees - Your clinician’s session fee is $200 for a 53-minute session. His/Her hourly fee

for other professional services is also $200 and is broken down if periods of less than one hour are

worked. Other services include report writing, telephone conversations lasting more than five

minutes, consulting with other professionals with your permission, preparation of records or

treatment summaries, and the time spent performing other services you may request. If you becomeinvolved in legal proceedings that require Your clinician’s participation, you will be expected to pay

for all his/her professional time, including preparation and transportation costs, even if he/she is

called to testify by another party. Because of the complexity of legal involvement, your clinician

charges $500 per hour for preparation and attendance at any legal proceeding + reimbursement of

transportation/lodging and other associated costs. To cover administrative and processing fees, if

payment owed is not remitted within 90 days of the service provided, a monthly 5% interest will be

applied to the remaining balance until paid in full. If a payment plan has not been agreed upon within

90 days, your balance may be submitted to a collection agency, which will involve sharing your

personal information. All payment is accepted in the form of check, cash, or credit card.

Insurance Reimbursement – Horizons Holistic Healing is an OON provider and requires full

out-of-pocket payment at time of service. If you have OON benefits and would like to use them,

please request a superbill from your clinician/and or sign up with Mentaya. Your clinician will provide

you with the superbill at the end of each month and any assistance he/she can in helping you

understand what a superbill is and how it works; however, if your insurance plan does not provide

reimbursement for the service you are seeking (for any reason), you (not your insurance company)

are still responsible for full payment of associated fees. It is ultimately your responsibility to verify

that your OON benefits are accurate and to ensure you understand the scope of your benefits.

Insurance reimbursements are based on actual information and claims submitted and is subject to

eligibility, terms, limitations, and exclusions of your health care program. Should you choose to file

claims to your insurance, please be aware your contract with your health insurance company

requires claims include information relevant to the services rendered. Clinicians are required to

provide a clinical diagnosis and sometimes to provide additional clinical information which may

include copies of your entire Clinical Record. In such situations, your clinician will make every effort

to release only the minimum information that is necessary for the purpose requested. He/She has no

control over what the insurance company will do with it once it is in their possession.

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COMPLAINTS

If you feel your Provider has engaged in improper or unethical behavior, you can talk to them, or you

may contact the licensing board that issued your Provider's license, your insurance company (if

applicable), or the US Department of Health and Human Services. If you are unsatisfied with your

therapy experience, then you may speak with your therapist and/or their supervisor.

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Texas Behavioral Health Executive Council

333 Guadalupe St., Ste. 3-900

Austin, Texas 78701

Phone: 800-821-3205

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NOTICE OF PRIVACY POLICIES

Horizons Holistic Healing

(office) – 469.232.7909

2310 N Henderson Ave #1415

Dallas, TX 75206www.horizonsholistichealing.com

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NOTICE OF PRIVACY PRACTICES

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.

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Horizons Holistic Healing, PLLC, is committed to protecting your privacy. The Practice is required by

federal law to maintain the privacy of Protected Health Information (“PHI”), which is information that

identifies or could be used to identify you. The Practice is required to provide you with this Notice of

Privacy Practices (this “Notice”), which explains the Practice's legal duties and privacy practices and

your rights regarding PHI that we collect and maintain.

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YOUR RIGHTS

Your rights regarding PHI are explained below. To exercise these rights, please submit a written

request to the Practice at the address noted below.

To inspect and copy PHI.

• You can ask for an electronic or paper copy of PHI. The Practice may charge you a reasonable fee.

• The Practice may deny your request if it believes the disclosure will endanger your life or another

person's life. You may have a right to have this decision reviewed.

To amend PHI.

• You can ask to correct PHI you believe is incorrect or incomplete. The Practice may require you to

make your request in writing and provide a reason for the request.

• The Practice may deny your request. The Practice will send a written explanation for the denial and

allow you to submit a written statement of disagreement.

To request confidential communications.

• You can ask the Practice to contact you in a specific way. The Practice will say “yes” to all

reasonable requests.

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To limit what is used or shared.

• You can ask the Practice not to use or share PHI for treatment, payment, or business operations.

The Practice is not required to agree if it would affect your care.

• If you pay for a service or health care item out-of-pocket in full, you can ask the Practice not to

share PHI with your health insurer.

• You can ask for the Practice not to share your PHI with family members or friends by stating the

specific restriction requested and to whom you want the restriction to apply.

To obtain a list of those with whom your PHI has been shared.

• You can ask for a list, called an accounting, of the times your health information has been shared.

You can receive one accounting every 12 months at no charge, but you may be charged a

reasonable fee if you ask for one more frequently.

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To receive a copy of this Notice.

• You can ask for a paper copy of this Notice, even if you agreed to receive the Notice electronically.

To choose someone to act for you.

• If you have given someone medical power of attorney or if someone is your legal guardian, that

person can exercise your rights.

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To file a complaint if you feel your rights are violated.• You can file a complaint by contacting the Practice using the following information:

Horizons Holistic Healing

Attn: Sonia Hopkins, Owner

PO Box 190281

Dallas, TX 75219

(office) – 469.232.7909

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• You can file a complaint with the U.S. Department of Health and Human Services Office for Civil

Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling

1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/.

• The Practice will not retaliate against you for filing a complaint.

To opt out of receiving fundraising communications.

• The Practice may contact you for fundraising efforts, but you can ask not to be contacted again.

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OUR USES AND DISCLOSURES

1. Routine Uses and Disclosures of PHI

The Practice is permitted under federal law to use and disclose PHI, without your written

authorization, for certain routine uses and disclosures, such as those made for treatment, payment,

and the operation of our business. The Practice typically uses or shares your health information in

the following ways:

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To treat you.

• The Practice can use and share PHI with other professionals who are treating you.

• Example: Your primary care doctor asks about your mental health treatment.

To run the health care operations.

• The Practice can use and share PHI to run the business, improve your care, and contact you.

• Example: The Practice uses PHI to send you appointment reminders if you choose.

To bill for your services.

• The Practice can use and share PHI to bill and get payment from health plans or other entities.

• Example: The Practice gives PHI to your health insurance plan so it will pay for your services.

2. Uses and Disclosures of PHI That May Be Made Without Your Authorization or Opportunity to

Object

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The Practice may use or disclose PHI without your authorization or an opportunity for you to object,

including:

To help with public health and safety issues

• Public health: To prevent the spread of disease, assist in product recalls, and report adverse

reactions to medication.

• Required by the Secretary of Health and Human Services: We may be required to disclose your

PHI to the Secretary of Health and Human Services to investigate or determine our compliance with

the requirements of the final rule on Standards for Privacy of Individually Identifiable Health

Information.

• Health oversight: For audits, investigations, and inspections by government agencies that oversee

the health care system, government benefit programs, other government regulatory programs, and

civil rights laws.• Serious threat to health or safety: To prevent a serious and imminent threat.

• Abuse or Neglect: To report abuse, neglect, or domestic violence.

To comply with law, law enforcement, or other government requests

• Required by law: If required by federal, state or local law.

• Judicial and administrative proceedings: To respond to a court order, subpoena, or discovery

request.

• Law enforcement: For law locate and identify you or disclose information about a victim of a crime.

• Specialized Government Functions: For military or national security concerns, including

intelligence, protective services for heads of state, or your security clearance.

• National security and intelligence activities: For intelligence, counterintelligence, protection of the

President, other authorized persons or foreign heads of state, for purpose of determining your own

security clearance and other national security activities authorized by law.

• Workers' Compensation: To comply with workers' compensation laws or support claims.

To comply with other requests

• Coroners and Funeral Directors: To perform their legally authorized duties.

• Organ Donation: For organ donation or transplantation.

• Research: For research that has been approved by an institutional review board.

• Inmates: The Practice created or received your PHI in the course of providing care.

• Business Associates: To organizations that perform functions, activities or services on our behalf.

3. Uses and Disclosures of PHI That May Be Made With Your Authorization or Opportunity to Object

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Unless you object, the Practice may disclose PHI:

To your family, friends, or others if PHI directly relates to that person's involvement in your care.

If it is in your best interest because you are unable to state your preference.

4. Uses and Disclosures of PHI Based Upon Your Written Authorization

The Practice must obtain your written authorization to use and/or disclose PHI for the following

purposes:

Marketing, sale of PHI, and psychotherapy notes.

You may revoke your authorization, at any time, by contacting the Practice in writing, using the

information above. The Practice will not use or share PHI other than as described in Notice unless

you give your permission in writing.

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OUR RESPONSIBILITIES

• The Practice is required by law to maintain the privacy and security of PHI.

• The Practice is required to abide by the terms of this Notice currently in effect. Where more

stringent state or federal law governs PHI, the Practice will abide by the more stringent law.

• The Practice reserves the right to amend Notice. All changes are applicable to PHI collected and

maintained by the Practice. Should the Practice make changes, you may obtain a revised Notice by

requesting a copy from the Practice, using the information above, or by viewing a copy on the

website: www.horizonsholistichealing.com

• The Practice will inform you if PHI is compromised in a breach.

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This Notice is effective on 09/27/2024

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INDIVIDUAL’S RIGHT TO RECEIVE A GOOD FAITH ESTIMATE

• 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.

• Make sure your health care provider gives you a Good Faith Estimate

• 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

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