The No Surprises Health Service Act: Good Faith Estimate

(2799B-6 of the Public Health Service Act, January 2022)

You have the right to receive a “Good Faith Estimate” explaining how much your treatment will cost. Under the law, all health care providers need to provide their patients an estimate of their bill for services – if their patients don’t have insurance or will not be using insurance.

You have the right to receive a Good Faith Estimate for the total expected cost of any of your services.

You can also ask for a Good Faith Estimate before you schedule a service. (If you receive a bill that is $400 more than the Good Faith Estimate you received, you can dispute the bill).

Make sure to save a copy or picture of your Good Faith Estimate.

Notice of HIPAA Notice of Privacy Practices

This notice describes how information about you may be used and discloses and how you can access this information. Haven Counseling Collective holds your protected health information in the strictest of confidence.

Our Legal Duty:

Haven Counseling Collective is legally obligated to keep your protected health information private. This includes any information that can identify you or your minor, including information regarding diagnoses, treatment, and payment for treatment.

How We Collect Information:

Haven Counseling Collective therapists collect data through a variety of means including, but not necessarily limited to, letters, phone calls, emails, and information provided directly from you. We may collect information from medical, psychological and collaboration with other health professionals involved with your care.

When, why, and how we will Use and Disclose Your Information:

Haven Counseling Collective will use (within our practice) and disclose (share with a third party) your protected health information under the following conditions:

Treatment: We will use and disclose your protected health information with physicians, psychologists, or any other licensed provider involved in your care, with your written permission.

Health Care Operations:

Haven Counseling Collective will use and disclose your protected health information to facilitate the efficient and correct operation of our agency. For example, we may also share your information with our attorneys, accountants, consultants, and other business associates to ensure that we are following and in compliance with all applicable laws. Haven Counseling Collective may use or disclose your protected health information for purposes outside of those mentioned above when your appropriate authorization is obtained first, before releasing this information.

Certain circumstances require to disclose your protected health information without your prior consent:

Your or your child’s information will be released in cases of:

• Child Abuse and Adult/Elder Abuse and/or Serious Threat to Health or Safety of Self or Others

Confidential Communication:

You may receive confidential communications from Haven Counseling Collective regarding protected health information. For example, you may request information be sent to an alternate address, such as your work address.

Access To Your File:

You may inspect and request a copy of your protected health information or a summary of the information.

How to File a Complaint:

The Board of Behavioral Sciences receives and responds to complaints regarding services provided within the scope of practice of Marriage and Family Therapists and Professional Clinical Counselors this includes Associate MFT’s and Associate PCC’s. You may contact the board online at www.bbs.ca.gov, or by calling (916) 574-7830 to file a complaint.