The Health Insurance Portability & Accountability Act of 1996 (HIPAA) requires all health care records and other individually identifiable health information (protected health information) used or disclosed to us in any form, whether electronically, on paper, or orally, be kept confidential. This federal law gives you, the patient, significant new rights to understand and control how your health information is used. HIPAA provides penalties for covered entities that misuse personal health information. As required by HIPAA, we have prepared this explanation of how we are required to maintain the privacy of your health information and how we may use and disclose your health information.

Without specific written authorization, we are permitted to use and disclose your health care records for the purposes of treatment, payment, and health care operations.
 - Treatment means providing, coordinating, or managing health care and related services by one or more health care providers. Examples of treatment would include psychotherapy, medication management, etc.
 - Payment means such activities as obtaining reimbursement for services, confirming coverage, billing or collection activities, and utilization review. An example of this would be billing your insurance company for your services.
 - Health Care Operations include the business aspects of running our practice, such as conducting quality assessment and improvement activities, auditing functions, cost-management analysis, and customer service. An example would include a periodic assessment of our documentation protocols, etc.

In addition, your confidential information may be used to remind you of an appointment (by phone or mail) or provide you with information about treatment options or other health-related services. We will use and disclose your PROTECTED HEALTH INFORMATION when we are required to do so by federal, state or local law.

We may disclose your PROTECTED HEALTH INFORMATION to public health authorities that are authorized by law to collect information; to a health oversight agency for activities authorized by law included but not limited to: response to a court or administrative order, if you are involved in a lawsuit or similar proceeding; response to a discovery request, subpoena, or other lawful process by another party involved in the dispute, but only if we have made an effort to inform you of the request or to obtain an order protecting the information the party has requested. We may release your PROTECTED HEALTH INFORMATION to a medical examiner or coroner to identify a deceased individual or to identify the cause of death. We may use and disclose your PROTECTED HEALTH INFORMATION when necessary to reduce or prevent a serious threat to your health and safety or the health and safety of another individual or the public. Under these circumstances, we will only make disclosures to a person or organization able to help prevent the threat.

Any other uses and disclosures will be made only with your written authorization. You may revoke such authorization in writing, and we are required to honor and abide by that written request, except to the extent that we have already taken actions relying on your authorization.

You have certain rights in regard to your PROTECTED HEALTH INFORMATION, which you can exercise by presenting a written request to our Privacy Officer at the practice address listed below:

 - The right to request restrictions on certain uses and disclosures of PROTECTED HEALTH INFORMATION, including those related to disclosures to family members, other relatives, close personal friends, or any other person identified by you. We are, however, not required to agree to a requested restriction. If we do agree to a restriction, we must abide by it unless you agree in writing to remove it.
 - The right to request to receive confidential communications of PROTECTED HEALTH INFORMATION from us by alternative means or at alternative locations.
 - The right to request an amendment to your PROTECTED HEALTH INFORMATION outside of treatment, payment and health care operations.
 - The right to obtain a paper copy of this notice for us upon request. We are required by law to maintain the privacy of your PROTECTED HEALTH INFORMATION and to provide you with notice of our legal duties and privacy practices with respect to PROTECED HEALTH INFORMATION.

We are required to abide by the terms of the Notice of Privacy Practices currently in effect. We reserve the right to change the terms of our Notice of Privacy Practices and to make the new notice provisions effective for all PROTECTED HEALTH INFORMATION that we maintain. Revisions to our Notice of Privacy Practices will be posted on the effective date and you may request a written copy of the Revised Notice from this office.

You have the right to file a formal, written complaint with us at the address below, or with the Department of Health & Human Services, Office of Civil Rights, in the event you feel your privacy rights have been violated. We will not retaliate against you for filing a complaint.

For more information about our Privacy Practices, please contact:

The Privacy Officer
Samantha Kay, MS, LMHC
1317 Edgewater Dr #1446
Orlando, FL 32804
407-603-5806

For more information about HIPAA or to file a complaint:
The U.S. Department of Health & Human Services
Office of Civil Rights
200 Independence Avenue, S.W. Washington, D.C. 20201
877.696.6775 (toll-free)

Under the Health Insurance Portability and Accountability Act (HIPAA) of 1996, you have specific privacy rights as a client of mental health services. The purpose of this form is to notify you of these rights.

Under HIPAA, you have the right to:
1. Inspect your own health information and obtain a copy (excluding psychotherapy notes).
2. Request an amendment to health information (excluding psychotherapy notes).
3. Receive an accounting of disclosures for purposes other than treatment, payment, and healthcare operations.
4. Request that uses and disclosures of health information be restricted.
5. File a privacy complaint with me and/or the Secretary of HHS (Department of Health and Human Services).

To file a complaint with me, you must do it in writing and you may either give it to me at your next appointment or send it by mail to the above address.

To file a complaint with the Secretary of HHS, you may go to the internet address:
http://cms.hhs.gov/hipaa/hipaa2/default.asp or you may mail your complaint in writing to HIPAA Complaint, 7500 Security Blvd., C5-24-04, Baltimore, MD 21244.The information needed to file a complaint is your name, address, phone number, the name of the provider you are filing the complaint about, the provider's Tax Identification Number, and the provider's address and telephone number. As your provider, I have a legal responsibility under Federal Law and HIPAA to protect your health information and to release only the minimum necessary information for the purposes of treatment, payment or healthcare operations, unless otherwise specifically authorized by you.

Everything you discuss with me will be kept in the strictest confidence, except for

matters pertaining to 1) plans to harm yourself or someone else, 2) the abuse or neglect of minors, the elderly, or persons with disabilities, 3) illegal activity resulting in a court order, 4) information required for payment, and 5) anything else required by law. For any of these matters, I would legally and ethically be required to break confidentiality and involve others. Of course, I am also willing to share information with any other professional or agency you wish me to, if you sign an authorization form permitting me to release specific information to the named person or agency.

I fully understand what I have read and that I will receive a copy of this "Notice of Privacy Rights and Practices". I also understand that if there are any changes to this form I will be notified in writing and given a new form to sign, as well as a copy. I have had an opportunity to ask questions regarding the policies.

Hands to Heart Wellness/ Samantha Kay
EIN: 93-1479165
NPI: 1003276353

You are entitled to receive this "Good Faith Estimate" of what the charges could be for psychotherapy services provided to you. While it is not possible for a psychotherapist to know, in advance, how many psychotherapy sessions may be necessary or appropriate for a given person, this form provides an estimate of the cost of services provided. Your total cost of services will depend upon the number of psychotherapy sessions you attend, your individual circumstances, and the type and amount of services that are provided to you.

This estimate is not a contract and does not oblige you to obtain any services from the provider listed, nor does it include any services rendered to you that are not identified here.

This Good Faith Estimate is not intended to serve as a recommendation for treatment or a prediction that you may need to attend a specified number of psychotherapy visits. The number of visits that are appropriate in your case, and the estimated cost for those services, depends on your needs and what you agree to in consultation with your practitioner. You are entitled to disagree with any recommendations made to you concerning your treatment and you may discontinue treatment at any time.

The date of this GFE is the date that it is sent to you via the Counsol client portal or the date you sign with your practitioner.

Common Services at Hands to Heart Wellness:
 - 90791: Initial therapy intake
 - 90837: Psychotherapy session (approx. 53+ minute)
 - 90847: Family/Couples psychotherapy session

Common Diagnosis Codes at Hands to Heart Wellness:
Below are common diagnosis codes at Hands to Heart Wellness; however, the list is not exhaustive. With that said, diagnosis codes can change based on many factors. Please speak to your practitioner with any questions or concerns.
 - F32.9: Major Depressive Disorder, Unspecified
 - F41.1: Generalized Anxiety Disorder
 - F43.1: Post-Traumatic Stress Disorder (PTSD)
 - F43.10: PSTD, Unspecified
 - Z13.30: Encounter for screening examination for mental health & behavioral disorders
 - Z62.811: Personal history of psychological/emotional abuse/neglect in Childhood
 - Z62.820: Parent/Child Relational ConflictV62.89/Z60.0: Phase of Life Problem
 - Z71.9: Other Counseling or Consulting
 - Z73.3: Stress not elsewhere specified

Hands to Heart Wellness recognizes that every client's therapy journey is unique. How long you need to engage in Psychotherapy and how often you attend sessions will be influenced by many factors including:
 - Your schedule and life circumstances
 - Provider availability
 - Ongoing life challenges
 - The nature of your specific challenges and how you address them
 - Personal finances

You and your provider will continually assess the appropriate frequency of therapy and will work together to determine when you have met your goals and are ready for discharge and/or a new "Good Faith Estimate" will be issued should your frequency or needs change. The psychotherapy relationship is always "at will" by either party.

Where services will be delivered: All services will be provided via telehealth at this time.

This estimate is based on IF you paid the practioner their FULL fee. This does not consider any sliding scale fee and we will not provide a new GFE for sliding scale adjusted fees. Your fees will never be increased without a discussion with your provider first, and the issuance of a new Good Faith Estimate.
 - Samantha Kay, LMHC / #MH15502 / NPI 1003276353/ $135/ hour

Client Good Faith Estimate Information
Client Diagnosis*: Z71.9 Other Counseling or Consulting (*This diagnosis is to satisfy the federal requirement for this form. This is not a formal clinical/psychological diagnosis.)
Total Good Faith Estimate for Hands to Heart Wellness: The following is a detailed list of expected services, items, and charges for Hands to Heart Wellness for standard fee of $135. Since we cannot determine the exact duration of service that you will receive, below you will find the total estimated cost of services for a variety of durations over the next 12 months.

Duration of Service Total Estimated Cost Service and Frequency
1 Session $135  90791, 90837, or 90847
13 Sessions (Approx. 3 Mths) $1,755, 1x/Per Week
26 Sessions (Approx. 6 mths) $3,510, 1x/Per Week
39 Sessions (Approx. 9 mths) $5,265, 1x/Per Week
52 Sessions (Approx. 12 Mths) $7,020, 1x/Per Week

You have a right to initiate a dispute resolution process if the actual amount charged to you substantially exceeds the estimated charges stated in your Good Faith Estimate (which means $400 or more beyond the estimated charges).

You are encouraged to speak with your provider at any time about any questions you may have regarding your treatment plan, or the information provided to you in this Good Faith Estimate.