Under Section 2799B-6 of the Public Health Service Act, the “No Surprises Act,” you have a right to receive a “good faith estimate” explaining how much your therapy services will cost.  Healthcare providers are required to provide clients who do not have insurance or who choose not to use their insurance for therapy services with an estimate of the cost of those services.

• You have the right to receive a Good Faith Estimate for the total cost of therapy services

• Make sure your therapist gives you a Good Faith Estimate in writing at least 1 business day before your appointment.  You may also ask your therapy for a Good Faith Estimate before you schedule an appointment.

• 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 HHS at 1-800-958-3059.

Impact Counseling Services, Inc is a Covered Entity and must comply with the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), the Health Information Technology for Economic and Clinical Health Act (“HITECH” or the “HITECH Act”), and Chapters 181 and 182 of the Texas Health & Safety Code. Please note that Chapter 181 of the Texas Health and Safety Code defines the term “Covered Entity” more broadly than does HIPAA in 45 C.F.R. §160.103. Covered entities as defined by Chapter 181 are required to comply with the applicable Chapter 181 provisions. If Impact Counseling Services, Inc obtains or creates information about your health, Impact Counseling Services, Inc is required by law to protect the privacy of your information. Protected health information (“PHI”) includes any information that relates to:

• Your past, present, or future physical or mental health or condition;

• Health care provided to you; and,

• Past, present, or future payment for your health care.

Impact Counseling Services, Inc may not disclose your PHI electronically without your authorization unless allowed by law. For example, the practice may share your PHI through approved, secure electronic methods for the purpose of treatment, payment for health care services, or health care operations such as case management or care coordination.

Impact Counseling Services, Inc may not disclose PHI electronically without separate authorization from you or your personal representative for each disclosure unless the disclosure is for treatment, payment, health care operations, an insurance or HMO function, or as otherwise authorized under state or federal law.

For a complete list of reasons that Impact Counseling Services, Inc is allowed by law to share your PHI, please refer to the Notice of Privacy Practices. This Notice will be provided upon the first date of delivery of health care services to you and is available upon request.