Legal Notices

Good Faith Estimate Standard Notice

“Right to Receive a Good Faith Estimate of Expected Charges” – Under the No Surprises ActYou have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost. A Good Faith Estimate will be available upon scheduling or upon request.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, please contact me

No Surprises Act 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.

Certain services at an in-network hospital or ambulatory surgical center

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 intensivist services. 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:

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

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

  3. 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.

  4. Count any amount you pay for emergency services or out-of-network services toward your deductible and out-of-pocket limit.

If you believe you’ve been wrongly billed, you may contact the Oregon Board of Psychology (503-378-4154 or psychology.board@oregon.gov) or the Oregon Division of Financial Regulation (dcbs.oregon.gov).

For more information about your rights under Federal law, visit: https://www.cms.gov/nosurprises

This notice describes how medical information about you may be used and disclosed, and how you can access this information. Please review it carefully.

Your Privacy Rights

As a client of PNW Anxiety Center you have the right to:

  • Access your health records, including receiving a copy of your medical and billing records.

  • Request corrections to your health records.

  • Request that your health information be kept private, with certain exceptions required by law.

  • Request limits on how your health information is used or disclosed, though we are not always required to agree to these requests.

  • Choose how we communicate with you (e.g., by phone, email, or mail).

  • Get a list of disclosures we have made of your health information, except for those for treatment, payment, and healthcare operations, or those authorized by you.

How We Use and Disclose Your Information

We may use and share your health information to:

  • Provide treatment: Your information may be shared with other healthcare providers involved in your care.

  • Obtain payment: We may use or disclose your information to obtain payment for services provided.

  • Manage healthcare operations: We use and share your information to run our practice and improve your care.

  • Respond to legal requirements: We will share information as required by law, such as reporting abuse or complying with court orders.

Additional Disclosures

We may also disclose your information in specific circumstances, such as:

  • Public health reporting

  • Legal proceedings

  • Health oversight activities

  • Law enforcement purposes

  • When required to avert a serious threat to your health or safety

Your Choices

You have some choices about how we use and share your information:

  • You can choose whether to share your information with family members or others involved in your care.

  • You may opt out of certain communications, like marketing or fundraising.

Our Responsibilities

We are required by law to:

  • Maintain the privacy and security of your protected health information (PHI).

  • Inform you of any breaches of your unsecured PHI.

  • Follow the duties and privacy practices described in this notice.

  • Provide you with a copy of this notice upon request.

Changes to This Notice

We may change this notice at any time, and the changes will apply to all information we have about you. The updated notice will be available in our office and on our website.

Contact Information

If you have any questions about this notice or need to file a complaint, you can contact me using this website’s contact form or using my contact information listed below this webpage.