• “Right to Receive a Good Faith Estimate of Expected Charges”


As a rule, I will disclose no information obtained from your contacts with me, or the fact that you are my patient, except with your written consent. However, there are some important exceptions to this rule of confidentiality – some exceptions created voluntarily by me, and some required by law. If you wish to receive mental health services from me, then under the Federal HIPAA regulations, you must sign below indicating that you understand and accept my policies about confidentiality and its limits. We will discuss these issues now, but you may re-open the conversation at any time during our work together.
**I. Uses and Disclosures Requiring Authorization or Consent**
HIPAA allows health care providers to use or disclose your protected health information (PHI) for treatment, payment, and health care operations purposes. In my own practice however, I do not disclose information routinely in these circumstances, so this will require your permission in advance, either through your consent at the onset of our relationship (by signing a general consent form), **or through your written authorization at the time the need for disclosure arises.
You may revoke your permission to release PHI, in writing, at any time, by contacting me. If there is an emergency and I cannot ask your permission, I am allowed to share information if I believe you would have wanted me to do so, or if I believe it will be helpful to you. Mental Health Medical Records is the term used for my formal record of the services provided to you, and these contain the dates of our sessions, your diagnosis, functional status, symptoms, prognosis and progress, and any psychological testing reports. “Psychotherapy notes” are notes I have made about our conversation during a private counseling session, which I have kept separate from the rest of your medical record. (Under HIPAA Regulations, such notes are given a greater degree of protection than the PHI or formal record, because they are considered my own private communication. However, Pennsylvania law does not protect such records from subpoena.)
**II. Possible Uses and Disclosures with Neither Consent nor Authorization**
I may use or disclose PHI without your consent or authorization in the following circumstances by policy, or if legally
· Child Abuse Reporting: If I have reason to suspect that a child is abused or neglected, I am required by Pennsylvania law to report the matter immediately to the Pennsylvania Department of Public Welfare.
· Adult Abuse Reporting: If I have reason to suspect that an elderly or incapacitated adult is abused, neglected or exploited, I am required by Pennsylvania law to immediately make a report and provide relevant information to the Pennsylvania Department of Health.
· Health Oversight: Pennsylvania law requires that I report misconduct by a health care provider of my own profession. By policy, I also reserve the right to report misconduct by health care providers of other professions. By law, if you describe unprofessional conduct by another mental health provider of any profession, I am required to explain to you how to make such a report. If you are yourself a health care provider, I am required by law to report that you are in treatment if I believe that your condition places the public at risk. Pennsylvania Licensing Boards have the power, when necessary, to subpoena relevant records in investigating a complaint of provider incompetence or misconduct.
· Court Proceedings: If you are involved in a court preceding and a request is made for information about your diagnosis and treatment and the records thereof, such information is privileged under state law, and I will not release information without your written authorization, unless a judge issues a court order. If I receive a subpoena for records or testimony, I will notify you so you can file a motion to quash (block) the subpoena. However, while awaiting the
judge’s decision, I am required to place said records in a sealed envelope and provide them to the Clerk of Court.
· Serious Threat to Health or Safety: Under Pennsylvania law, if I am engaged in my professional duties and you communicate to me a specific and immediate threat to cause serious bodily injury or death to an identified or to an identifiable person, and I believe you have the intent and ability to carry out that threat immediately or imminently, I am legally required to take steps to protect third parties. These precautions may include 1) warning the potential victim(s), or the parent or guardian of the potential victim(s), if under 18, 2) notifying a law enforcement officer, or 3) seeking your hospitalization. I may also use and disclose medical information about you when necessary to prevent an immediate, serious threat to your own health and safety.
· Workers Compensation: If you file a worker’s compensation claim, I am required by law, upon request, to submit your relevant mental health information to you, your employer, the insurer, or a certified rehabilitation provider.
Other uses and disclosures of information not covered by this notice or by the laws that apply to me will be made only with your written permission.
**III. Definitions**
· “PHI” (Protected Health Information) refers to information in your health record that could identify you.
· “Treatment, Payment and Health Care Operations” –Treatment is when I provide, coordinate or manage your health care and other services related to your health care. An example of a disclosure related to treatment would be when I consult with another health care provider, such as your PCP or psychiatrist. –Payment is when I obtain reimbursement for your healthcare. Examples of disclosure for payment purposes are when I 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 my 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.
**NOTE: **Your records are kept in a locked filing.
· “Use” applies only to activities within my office, such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.
· “Disclosure” applies to activities outside of my office, such as releasing, transferring or providing access to information about you to other parties.
· “Consent” is a general permission that allows me to use and disclose your health care information for routine purposes of treatment, payment and operations. For example, under the law, you must sign a consent form before I can begin to see you for therapy or provide other mental health services.
·”Authorization” is required by law and involves your written permission to use and disclose information not covered by the consent form. There are a few cases (see above) in which I am allowed, even required, to use and disclose your information without your consent or authorization. I will keep a record of disclosures, and this will be available to you.
**IV. Patient’s Rights and Provider’s Duties**
· Right to Request Restrictions-You have the right to request restrictions on certain uses and disclosures of protected health information about you. You also have the right to request a limit on the medical information I disclose about you to someone who is involved in your care or the payment for your care. If you ask me to disclose information to another party, you may request that I limit the information I disclose. However, I am not required to agree to a restriction you request. To request restrictions, you must make your request in writing, and tell me: 1)what information you want to limit; 2) whether you want to limit my use, disclosure or both; and 3) to whom you want the limits to apply.
· 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 me. Upon your request, I will send your bills to another address. You may also request that I contact you only at work, or that I do not leave voice mail messages.) To request alternative communication, you must make your request in writing, specifying how or where you wish to be contacted.
· Right to an Accounting of Disclosures – 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 written request, I will discuss with you the details of the accounting process.
· Right to Inspect and Copy- In most cases, you have the right to inspect and copy your medical and billing records. To do this, you must submit your request in writing. If you request a copy of the information, I may charge a fee for costs of copying and mailing. I may deny your request to inspect and copy in some circumstances. I may refuse to provide you access to certain psychotherapy notes or to information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative proceeding.
· Right to Amend – If you feel that protected health information I have about you is incorrect or incomplete, you may ask me to amend the information. To request an amendment, your request must be made in writing, and submitted to me. In addition, you must provide a reason that supports s your request. I may deny your request if you ask me to amend information that:
1) was not created by me; I will add your request to the information record;
2) is not part of the medical information kept by me;
3) is not part of the information which you would be permitted to inspect and copy;
4) is accurate and complete.
· Right to a copy of this notice – You have the right to a paper copy of this notice. You may ask me to give you a copy of this notice at any time. Changes to this notice: I reserve the right to change my policies and/or to change this notice, and to make the changed notice effective for medical information I already have about you as well as any information I receive in the future. The notice will contain the effective date. A new copy will be given to you or posted in the waiting room. I will have copies of the current notice available on request.
Complaints: If you believe your privacy rights have been violated, you may file a complaint. To do this, you must submit your request in writing to my office. You may also send a written complaint to the U.S. Department of Health and Human Services.

“Right to Receive a Good Faith Estimate of Expected Charges”

Under the 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 one business day before your medical service or item. You can also ask your health care 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 or call Dr. Burman at 484-441-3682.

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