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
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.
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.
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.
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.
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.
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:
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.
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.
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.
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.
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.
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:
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.
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.
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)
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.
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.
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.
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.
Texas Behavioral Health Executive Council
333 Guadalupe St., Ste. 3-900
Austin, Texas 78701
Phone: 800-821-3205
NOTICE OF PRIVACY POLICIES
Horizons Holistic Healing
(office) – 469.232.7909
2310 N Henderson Ave #1415
Dallas, TX 75206www.horizonsholistichealing.com
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.
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.
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.
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.
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.
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
• 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.
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:
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
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
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.
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.
This Notice is effective on 09/27/2024
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