HIPAA DISCLOSURE FORM – BRIEF VERSION

   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.

 My commitment to your privacy

My practice is dedicated to maintaining the privacy of your personal health information as part of providing professional

care. I am also required by law to keep your information private. These laws are complicated, and I am required by law to give you this important information. 

 How I use and disclose your protected health information with your consent

I will use the information collected about you mainly to provide you with treatment, to arrange payment for my services, and for some other business activities that are called, in the law, health care operations. After you have read this notice I will ask you to sign a consent form to let me use and share your information in these ways. If you do not consent and sign this form, I cannot work therapeutically with you. If I want to use or send, share, or release your information for other purposes, I will discuss this with you and ask you to sign an authorization form to allow this.

 Disclosing your health information without your consent

There are some times when the laws require me to use or share your information. For example:

1. When there is a serious threat to yours or another’s health and safety or to the public. I will only share information with persons  who are able to help prevent or reduce the threat.

2. When I am required to do so by lawsuits and other legal or court proceedings.

3. If a law enforcement official requires me to do so.

4. For workers’ compensation and similar benefit programs.

There are some other rare situations. They are described in the longer version of our notice of privacy practices.

 Your rights regarding your health information

1. You can ask me to communicate with you in a particular way or at a certain place that is more private for you. For example, you can ask me to call you at home, and not at work, to schedule or cancel an appointment. I will try my best to do as you ask.

2. You can ask me to limit what I tell people involved in your care or the payment for your care, such as family members and friends.

3. You have the right to look at the health information I have about you, such as your medical and billing records. You can get a copy of these records, but I may charge you for it.

4. If you believe that the information in your records is incorrect or missing something important, you can ask me to make additions to your records to correct the situation through a request in writing. You must also tell me the reasons you want to make the changes.

 5. You have the right to a copy of this notice. If I change this notice I will post the new version in our waiting area, and you can always get a copy of it.

6. You have the right to file a complaint if you believe your privacy rights have been violated. You can file a complaint with me and with the Secretary of the U.S. Department of Health and Human Services. All complaints must be in writing. Filing a complaint will not change the health care we provide to you in any way. Also, you may have other rights that are granted to you by the laws of our state, and these may be the same as or different from the rights described above. I will be happy to discuss these situations with you now or as they arise. If you have any questions regarding this notice or my health information privacy policies, please contact me by phone at: 970.319.9960 or by my address: 8341 S. Sangre De Cristo Rd. Suite 204, Littleton, CO, 80127.

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YOUR RIGHTS AND PROTECTIONS AGAINST SURPRISE MEDICAL BILLS

(OMB Control Number: 0938-1401) 

When you get emergency care or get treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from surprise billing or balance billing.

What is “balance billing” (sometimes called “surprise billing”)?

When you see a doctor or other health care provider, you may owe certain out-of-pocket costs,     such as a copayment, coinsurance, and/or a deductible. You may have other costs or have to pay the entire bill if you see a provider or visit a health care facility that isn’t in your health plan’s network.

“Out-of-network” describes providers and facilities that haven’t signed a contract with your health plan. Out-of-network providers may be permitted to bill you for the difference between what your plan agreed to pay and the full amount charged for a service. This is called “balance billing.” This amount is likely more than in-network costs for the same service and might not count toward your annual out-of-pocket limit.

“Surprise billing” is an unexpected balance bill. This can happen when you can’t control who is involved in your care - like when you have an emergency or when you schedule a visit at an in-network facility but are unexpectedly treated by an out-of-network provider.

You are protected from balance billing for Emergency Services. If you have an emergency medical condition and get emergency services from an out-of-network provider or facility, the most the provider or facility may bill you is your plan’s in-network cost-sharing amount (such as copayments and coinsurance). You can’t be balance billed for these emergency services. This includes services you may get after you’re in stable  condition, unless you give written consent and give up your protections not to be balanced billed for these post-stabilization services.

When you get services from an in-network hospital or ambulatory surgical center, certain providers there may be out-of-network. In these cases, the most those providers may bill you is your plan’s in-network cost-sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivistservices. These providers can’t balance bill you and may not ask you to give up your protections  not to be balance billed.

If you get other services at these in-network facilities, out-of-network providers can’t balance  bill you unless you give written consent and give up your protections.

You’re never required to give up your protection from balance billing. You also aren’t required to get care out-of-network. You can choose a provider or facility in your plan’s network.

When balance billing isn’t allowed, you also have the following protections:

·       You are only responsible for paying your share of the cost (like the copayments, coinsurance, and deductibles that you would pay if the provider or facility was in-network). Your health plan will pay out-of-network providers and facilities directly.

·       Your health plan generally must:

o   Cover emergency services without requiring you to get approval for services in advance (prior authorization).

o   Cover emergency services by out-of-network providers.

o   Base what you owe the provider or facility (cost-sharing) on what it would pay an in-network provider or facility and show that amount in your explanation of benefits.

o   Count any amount you pay for emergency services or out-of-network services toward your deductibleand out-of-pocket limit. 

If you believe you’ve been wrongly billed, you may contact: Kate King at (970)319-9960 or katekingtherapy@gmail.com  

Visit https://www.cms.gov/files/document/model-disclosure-notice-patient-protections-against-surprise-billing-providers-facilities-health.pdf for more information about your rights under Federal law.

Visit https://www.sos.state.co.us for more information about your rights under Colorado state law.