Good Faith Estimate Patient Notice

You have the right to receive a “Good Faith Estimate” explaining how much your health care will cost.

Under federal law, health care providers need to give uninsured and self-pay patients (including patients with health insurance that decide to be self-pay for a specific item or service) an estimate of their bill for health care items and services before those items or services are provided.

• You have the right to receive a Good Faith Estimate for the total expected cost of any health care items or services upon request or when scheduling such items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees.

• If you schedule a health care item or service at least 3 business days in advance, make sure your health care provider or facility gives you a Good Faith Estimate in writing within 1 business day after scheduling. If you schedule a health care item or service at least 10 business days in advance, make sure your health care provider or facility gives you a Good Faith Estimate in writing within 3 business days after scheduling. You can also ask any health care provider or facility for a Good Faith Estimate before you schedule an item or service. If you do, make sure the health care provider or facility gives you a Good Faith Estimate in writing within 3 business days after you ask.

• If you receive a bill that is at least $400 more for any provider or facility than your Good Faith Estimate from that provider or facility, you can dispute the bill.

For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises/consumers, email FederalPPDRQuestions@cms.hhs.gov, or call 1- 800-985-3059.

PRIVACY ACT STATEMENT: CMS is authorized to collect the information on this form and any supporting documentation under section 2799B-7 of the Public Health Service Act, as added by section 112 of the No Surprises Act, title I of Division BB of the Consolidated Appropriations Act, 2021 (Pub. L. 116-260). We need the information on the form to process your request to initiate a payment dispute, verify the eligibility of your dispute for the PPDR process, and to determine whether any conflict of interest exists with the independent dispute resolution entity selected to decide your dispute. The information may also be used to: (1) support a decision on your dispute; (2) support the ongoing operation and oversight of the PPDR program; and (3) evaluate selected IDR entity’s compliance with program rules. Providing the requested information is voluntary. But failing to provide it may delay or prevent processing of your dispute, or it could cause your dispute to be decided in favor of the provider or facility.

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Notice of Privacy Practices

This Notice of Privacy Practices (the “Notice”) describes how your medical record and treatment information may be used and disclosed and how you can get access to this information.

Your Rights: When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.

• Get an electronic or paper copy of your medical record

• Ask us to correct your medical record

• Request confidential communications

• Ask us to limit health information we use or share

• Get a list (called an “accounting”) of those with whom we’ve shared your health information

• Get a copy of this Notice

• Choose someone to act for you

• File a complaint with us or with HHS if you feel your rights are violated

Your Choices: For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.

In these cases, you have both the right and choice to tell us to:

• Share information with your family, close friends, or others involved in your care

• Share information in a disaster relief situation

• In these cases, we never share your information unless you give us written permission:

• Marketing purposes

• Sale of your information

• Most sharing of psychotherapy notes

Our Uses and Disclosures: How do we typically use or share your health information? We typically use or share your health information in the following ways.

• We can use your health information and share it with other professionals who are treating you.

• We can use and share your health information to run our practice, improve your care, and contact you when necessary.

• We can use and share your health information to bill and get payment from health plans or other entities.

How else can we use or share your health information? We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research, and are expressly permitted by HIPAA.

• Help with public health and safety issues

• Do research

• Comply with the law

• Respond to lawsuits and legal actions

Our Responsibilities

• We are required by law to maintain the privacy and security of your protected health information.

• We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.

• We must follow the duties and privacy practices described in this Notice and give you a copy of it.

• We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.

Changes to the Terms of this Notice:

This Notice describes how Hunt Psychological Services LLC may use and disclose your protected health information. We can change the terms of this Notice, and the changes will apply to all information we have about you. The new Notice will be available upon request, in our office, and on our web site.

Contact Information: If you have any questions about this Notice, or have a complaint, then please contact the following Privacy Officer:

Steven Hunt, PhD, NCSP

941 River Road, Suite A

Granville, Ohio, 43023

You can also 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., Room 509F HHH Bldg., Washington, D.C. 20201, by sending an email to OCRComplaint@hhs.gov, by calling 1-877-696-6775, or by visiting www.hhs.gov/ocr/privacy/hipaa/complaints/