Good Faith Estimate Notice
In accordance with the Federal No Surprises Act
You have the right to receive a "Good Faith Estimate" explaining how much your medical care will cost.
Under the law, health care providers need to give patients who don't have insurance or who are not using insurance an estimate of the bill for medical items and services.
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 in writing at least 1 business day before your medical service or item. You can also ask your healthcare provider, and any other provider you choose, for a Good Faith Estimate before you schedule an item or service.
- 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 or call 1-800-985-3059.
Notice of Privacy Practices and Policies Regarding Health Information
THIS NOTICE DESCRIBES HOW MENTAL HEALTH AND MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
- Uses and Disclosures for Treatment, Payment, and Health Care Operations
This agency may use or disclose your protected health information (PHI), for treatment, payment, and health care operations purposes with your consent. To help clarify these terms, here are some definitions:
- "TNCG" and "We" and "Us" refer to employees and affiliates of True North Counseling Group.
- "Patient" and "Client" refers to you, the client of TNCG, receiving "treatment" from a TNCG provider.
- "PHI" refers to information in your health record that could identify you.
- "Treatment, Payment, and Health Care Operations"
- Treatment is when staff of this agency provide, coordinate or manage your health care and other services related to your health care. An example of treatment would be when staff consult with another health care provider, such as your family physician or another mental health provider.
- Payment is when this agency obtains reimbursement for your healthcare. Examples of payment are when staff disclose your PHI to your health insurer to obtain reimbursement for your health care or to determine eligibility or coverage.
- Health Care Operations are activities that relate to the performance and operation of this practice. Examples of health care operations are quality assessment and improvement activities, business-related matters such as audits and administrative services, and case management and care coordination.
- "Use" applies only to activities within this agency such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.
- "Disclosure" applies to activities outside of this agency, such as releasing, transferring, or providing access to information about you to other parties.
- Uses and Disclosures Requiring Authorization
We may use or disclose PHI for purposes outside of treatment, payment, and health care operations when your appropriate authorization is obtained. An "authorization" is written permission above and beyond the general consent that permits only specific disclosures. In those instances when we are asked for information for purposes outside of treatment, payment, and health care operations, we will obtain an authorization from you before releasing this information. We will also need to obtain an authorization before releasing your records.
You may revoke all such authorizations at any time, provided each revocation is in writing. You may not revoke an authorization to the extent that (1) we have relied on that authorization; or (2) if the authorization was obtained as a condition of obtaining insurance coverage, and the law provides the insurer the right to contest the claim under the policy.
- Uses and Disclosures with Neither Consent nor Authorization
We may use or disclose PHI without your consent or authorization in the following circumstances:
- Child Abuse: If, in the staff's professional capacity, staff know or suspect that a child under 18 years of age or a mentally retarded, developmentally disabled, or physically impaired child under 21 years of age has suffered or faces a threat of suffering any physical or mental wound, injury, disability, or condition of a nature that reasonably indicates abuse or neglect, staff are required by law to immediately report that knowledge or suspicion to the Ohio Public Children Services Agency, or a municipal or county peace officer.
- Elder Abuse: If we have reasonable cause to believe that an adult is being abused, neglected, or exploited, or is in a condition which is the result of abuse, neglect, or exploitation, staff are required by law to immediately report such belief to the County Department of Job and Family Services.
- Judicial or Administrative Proceedings: If you are involved in a court proceeding and a request is made for information about your evaluation, diagnosis and treatment and the records thereof, such information is privileged under state law and we will not release this information without written authorization from you or your persona or legally appointed representative, or a court order. The privilege does not apply when you are being evaluated for a third party or where the evaluation is court ordered. You will be informed in advance if this is the case.
- Serious Threat to Health or Safety: If we believe that you pose a clear and substantial risk of imminent serious harm to yourself or another person, we may disclose your relevant confidential information to public authorities, the potential victim, other professionals, and/or your family in order to protect against such harm. If you communicate to us an explicit threat of inflicting imminent and serious physical harm or causing the death of one or more clearly identifiable victims, and we believe you have the intent and ability to carry out the threat, then we are required by law to take one or more of the following actions in a timely manner: 1) take steps to hospitalize you on an emergency basis, 2) establish and undertake a treatment plan calculated to eliminate the possibility that you will carry out the threat, and initiate arrangements for a second opinion risk assessment with another mental health professional, 3) communicate to a law enforcement agency and, if feasible, to the potential victim(s), or victim's parent or guardian if a minor, all of the following information: a) the nature of the threat, b) your identity, and c) the identity of the potential victim(s).
- Comply with the Law: We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we are complying with federal privacy law.
- Work with Medical Examiner or Funeral Director, Law Enforcement, or Public Health Agency: We can share health information with a coroner, medical examiner, or funeral director when a client dies. We can also share your information with law enforcement officials for special government functions such as military, national security, and presidential protective services. We can also share your information with public health oversight agencies for activities authorized by law.
- Worker's Compensation: If you file a worker's compensation claim, we may be required to give your mental health information to relevant parties and officials.
- Client's Rights and Provider's Duties
When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.
- Right to Request Restrictions - You have the right to request restrictions on certain uses and disclosures of protected health information about you. However, we are not required to agree to a restriction you request.
- Right to Receive Confidential Communications by Alternative Means and at Alternative Locations - You have the right to request and receive confidential communications of PHI by alternative means and at alternative locations. (For example, you may not want a family member to know that you are seeing us. Upon your request, we will send your bills to another address.) This information will be documented in your file.
- Special notice on email communications: TNCG recognizes that you may prefer email to communicate with us. Please be aware that information sent via email may not be secure. There is a possibility that information about you may be intercepted and read by others. We will ask for your permission before using unsecure email to communicate with you about your health care that involves your health information.
- Right to Inspect and Copy - You have the right to inspect or obtain a copy (or both) of PHI and psychotherapy notes and agency mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record. We may deny your access to PHI under certain circumstances, but in some cases, you may have this decision reviewed. On your request, we will discuss with you the details of the request process. It may take several days to arrange for the inspection of your records and/or to copy your records. A fee may be associated with the copying of your records.
- Right to Amend - You have the right to request an amendment of PHI for as long as the PHI is maintained in the record. We may deny your request. On your request, we will discuss with you the details of the amendment process.
- Right to an Accounting - You generally have the right to receive an accounting of disclosures of PHI for which you have neither provided consent nor authorization (as described in Section III of this Notice). On your request, we will discuss with you the details of the accounting process.
- Right to a Paper Copy - You have the right to obtain a paper copy of the notice from this agency upon request, even if you have agreed to receive the notice electronically.
- Right 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 and make choices about your health information. We will make sure the person has the authority and can act for you before we take any action.
Mental Health Provider's Duties:
- We are required by law to maintain the privacy of PHI and to provide you with a notice of our legal duties and privacy practices with respect to PHI.
- We reserve the right to change the privacy policies and practices described in this notice. Unless we notify you of such changes, however, we are required to abide by the terms currently in effect.
- If we revise these policies and procedures, the new policies and procedures will be posted on the agency web site: www.beyourtruenorth.com
- The agency 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 use or share your information, you may change your mind at any time, notifying us in writing.
- For more information, visit U.S. Department of Health and Human Services.
In the event of a breach, the agency will notify clients by written notice within 60 days of the date that the breach is discovered. Notices will be mailed to the last known address of the client.
- Questions and Complaints
If you have questions about this notice, disagree with a decision we make about access to your records, or have other concerns about your privacy rights, you may contact the Client's Rights Officer, Sonya Slater. If you believe that your privacy rights have been violated and wish to file a complaint with this agency, you may send your written complaint to:
True North Counseling Group
6209 Riverside Drive
Dublin, Ohio 43017
You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services. The person listed above can provide you with the appropriate address upon request. You have specific rights under the Privacy Rule. We will not retaliate against you for exercising your right to file a complaint.
This notice will go into effect on July 1, 2022. This agency reserves the right to change the terms of this notice and to make the new notice provisions effective for all PHI that is maintained. We will provide you with a revised notice by posting these changes to the agency website.