This page contains important information regarding your rights protected by HIPAA and receiving a Good Faith Estimate.
Please read over them carefully.
To file complaints see the appropriate information below:
Complaints about privacy practices should be directed to Tammy Kothe-Ramsey
TKR Counseling Services, PLLC
1214 18th Street, Suite B1, Hondo, TX 78861
To file a claim regarding the Good Faith Estimate contact www.cms.gov/nosurprises or call (800) 368-1019
To file a complaint regarding licensing contact the
Texas Behavioral Health Executive Counsel
333 Guadalupe St, Tower 3, Room 900
Austin, Texas 78701
toll-free system (800) 821-3205
License #77235 Expiration 1/31/2023
NPI # for Tammy Kothe Ramsey- 1487312120
NPI # for TKR Counseling Services PLLC- 1588335111
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.
TKR COUNSELING SERVICES PLLC HAS A LEGAL DUTY TO SAFEGUARD YOUR PROTECTED HEALTH INFORMATION (PHI).
TKR Counseling Services PLLC ("TKR COUNSELING") is legally required to protect the privacy of your PHI, which includes information that can be used to identify you which TKR COUNSELING created or received about your past, present, or future health or conditions, the provision of health care to you, or the payment for this health care. TKR COUNSELING must provide you with this Notice about our privacy practices, and such Notice must explain how, when, and why we will “use” and “disclose” your PHI. A “use” of PHI occurs when we share, examine, use, apply, or analyze such information within our practice; PHI is “disclosed” when it is released, transferred, has been given to, or is otherwise divulged to a third party outside of this practice. With some exceptions, TKR COUNSELING may not use or disclose any more of your PHI than is necessary to accomplish the purpose for which the use or disclosure is made. Also, TKR COUNSELING is legally required to follow the privacy practices described in this Notice. However, TKR COUNSELING reserves the right to change the terms of this Notice and our privacy policies at any time. Any changes will apply to PHI on file with is already. Before TKR COUNSELING makes any important changes to our policies, we will promptly change this Notice and post a new copy of it in the office. You can also request a copy of this Notice from us, or you can view a copy of it in the office.
HOW PERSONAL HEALTH INFORMATION (PHI) MAY BE USED AND DISCLOSED
TKR COUNSELING will use and disclose your PHI for many different reasons. For some of these uses or disclosures, I will need your prior authorization, for others, however, I do not. Listed below are the different categories of our uses and disclosures along with some examples.
1. Uses and Disclosures Relating to Treatment, Payment, or Health Care Operations Do Not Require Your Prior Written Consent. TKR COUNSELING can use and disclose your PHI without your consent for the following reasons:
a. For treatment. TKR COUNSELING can disclose your PHI to physicians, psychiatrists, psychologists, and other licensed health care providers who provide you with health care services or are involved in your care. For example, if you’re being treated by a psychiatrist, TKR COUNSELING can disclose your PHI to your psychiatrist in order to coordinate your care.
b. To obtain payment for treatment. TKR COUNSELING can use and disclose your PHI to bill and collect payment for the treatment and services provided by TKR COUNSELING to you. For example, TKR COUNSELING might send your PHI to your insurance company or health plan to get paid for the health care services that TKR COUNSELING have provided to you. TKR COUNSELING may also provide your PHI to our business associates, such as billing companies, claims processing companies and others that process our health care claims.
c. For health care operations. TKR COUNSELING can disclose your PHI to operate our practice. For example, we might use your PHI to evaluate the quality of health care services that you received or to evaluate the performance of the health care professionals who provided such services to you. We may also provide your PHI to our accountants, attorneys, consultants, and others to make sure we are complying with applicable laws.
d. Other disclosure. TKR COUNSELING may also disclose your PHI to others without your consent in certain situations. For example, your consent isn’t required if you need emergency treatment, as long as we try to get your consent but you are unable to communicate with us (for example, if you are unconscious or in severe pain) and we do not think that you would consent to such treatment if you were able to do so.
2. Certain Uses and Disclosures Do Not Require Your Consent. TKR COUNSELING can use your PHI without your consent or authorization for the following reasons:
a. When disclosure is required by federal, state or local law; judicial or administrative proceedings or law enforcement. For example, TKR COUNSELING may make a disclosure to applicable officials when a law requires me to report information to government agencies and law enforcement personnel about victims of abuse or neglect; or when ordered in a judicial or administrative proceeding.
b. For public health activities. For example, TKR COUNSELING may have to report information about you to the county coroner.
c. For health oversight activities. For example, TKR COUNSELING may have to provide information to assist the government when it conducts an investigation or inspection of a health care provider or organization.
d. For research purposes. In certain circumstances, TKR COUNSELING may provide PHI in order to conduct medical research.
e. To avoid harm. In order to avoid a serious threat to the health and safety of a person or the public, TKR COUNSELING may provide PHI to law enforcement personnel and veterans in certain situations. And TKR COUNSELING may disclose PHI for national security purposes such as protecting the President of the United States or conducting intelligence operations.
f. For specific government functions. TKR COUNSELING may disclose PHI of military personnel and veterans in certain situations. And TKRCOUNSELING may disclose PHI for national security purposes, such as protecting the President of the United States or conducting intelligence operations.
g. For workers’ compensation purposes. TKR COUNSELING may provide PHI in order to comply with workers’ compensation laws.
h. Appointment reminders and health related benefits or services. TKR COUNSELING may use PHI to provide appointment reminders or give you information about treatment alternatives or other health care services or benefits TKR COUNSELING offer.
3. Certain Uses and Disclosures Require that You Have the Opportunity to Object.
a. Disclosures to family, friends, or others. TKR COUNSELING may provide your PHI to a family member, friend, or other persons that you indicate is involved in your care or the payment for your health care, unless you object in whole or in part. The opportunity to consent may be obtained retroactively in emergency situations.
4. Other Uses and Disclosures Require Your Prior Written Authorization. In any other situation not described in sections III A, B, and C above TKR COUNSELING will ask for your written authorization before using or disclosing any of your PHI. If you choose to sign an authorization to disclose your PHI, you can later revoke such authorization in writing to stop any future uses and disclosures (to the extent that TKR COUNSELING hasn’t taken any action in reliance on such authorization) of your PHI by us.
WHAT RIGHTS YOU HAVE REGARDING YOUR PHI
You have the following rights with respect to your PHI
1. The Right to Request Limits on Uses and Disclosures of Your PHI. You have the right to ask that TKR COUNSELING limit how we use and disclose your PHI. TKR COUNSELING will consider your request, but we are not legally required to accept it. If we accept your request, we will put any limits in writing and abide by them except in emergency situations. You may not limit the uses and
disclosures that we are legally required or allowed to make.
2. The Right to Choose How to Send PHI to You. You have the right to ask that TKR COUNSELING send information to an alternative address (for example, sending information to your work address rather than your home address) or by alternate means (for example, email instead of regular mail). We must agree to your request so long as we can easily provide the PHI to you in the format you
3. The Right to See and Get Copies of Your PHI. In most cases, you have the right to look at and get copies of your PHI that we have, but you must make the request in writing. If we don’t have your PHI but know who does, you will be told how to get it. We will respond to you within 15 days of receiving your written request. In certain situations, we may deny your request. If so, you will receive an explanation in writing, the reasons for denial and explain your right to have our denial reviewed. If you request copies of your PHI, you will be charged $45 (for supplies and labor) if picked up in the office and $70 (includes shipping) if sent Fed Ex. Instead of providing the PHI you requested, you may be provided with a summary or explanation of the PHI as long as you agree to that and to the cost in advance.
4. The Right to Get a List of the Disclosures that Have Been Made.
a. You have the right to get a list of instances in which TKR COUNSELING have disclosed your PHI. The list will not include uses or disclosures that you have already consented to, such as those made for treatment, payment, or health care operations, directly to you, or to your family. The list also will not include uses and disclosures made for national security purposes, to corrections or law enforcement personnel.
b. TKR COUNSELING will respond to your request for an accounting of disclosures within 60 days of receiving your request. The list will include the date of the disclosure, to whom PHI was disclosed (including their address, if known), a description of the information disclosed, and the reason for the disclosure. TKR COUNSELING will provide the list to you at no charge but if you make more than one based request in the same year, you will be charged a reasonable fee for each additional request.
5. The Right to Correct or Update Your PHI. If you believe that there is a mistake in your PHI or that a piece of important information is missing, you have the right to request that your therapist correct the existing information or add the missing information. You must provide the request and your reason for the request in writing. TKR COUNSELING will respond within 60 days of receiving your request to correct or update your PHI. Your request may be denied in writing if the PHI is (i) correct and complete, (ii) not created by me (therapist is no longer with TKR COUNSELING), (iii) not allowed to be disclosed, or (iv) not part of our records. The written denial will state reasons for the denial and explain your right to file a written statement of disagreement with the denial. If you do not file one, you have the right to request that your request and our denial be attached to all future disclosures of your PHI. If your request is approved, changes will be made to your PHI, tell you when completed, and tell others that need to know about the change to your PHI.
6. The Right to Get This Notice by Email. You have the right to get a copy of this notice by email. Even if you have agreed to receive notice via email, you also have a right to request a paper copy of it.
HOW TO COMPLAIN ABOUT OUR PRIVACY PRACTICES
If you think TKR COUNSELING may have violated your privacy rights, or you disagree with a decision made about access to your PHI, you may file a complaint with the person listed in Section VI below. You may also send a written complaint to The US Department of Health & Human Services Office of Civil Rights at www.hhs.gov/ocr/hipaa/. Or, you may file a complaint to the Texas Behavioral Health Executive Counsel, 333 Guadalupe Street, Suite 3-900, Austin, TX 78701, Attention Enforcement Division or call 512-305-7700. You may also obtain a complaint form from your therapist. No retaliatory action against you will be taken if you file a complaint about our privacy practices.
PERSON TO CONTACT FOR INFORMATION ABOUT THIS NOTICE OR TO COMPLAIN ABOUT TKR COUNSELING SERVICES PRIVACY PRACTICES
If you have any questions about this notice or any complaints about our privacy practices, or would like to know how to file a complaint with the US Department of Heath & Human Services, please contact Tammy Kothe-Ramsey, 1214 18th Street, Suite B1, Hondo TX 78861, 830-444-5064, email@example.com.
EFFECTIVE DATE OF THE NOTICE
This notice went into effect on December 16, 2021
A Good Faith Estimate is available upon request or after scheduling services with a therapist employed by TKR Counseling Services PLLC ("TKR COUNSELING"). The purpose of a Good Faith Estimate is to provide you with information on the costs ahead of a service and potential out-of-network costs to help avoid surprise bills.
I will provide you with a Good Faith Estimate in several stages. Since the law requires a Good Faith Estimate within 1 day of scheduling, if the service is scheduled 3 days out, and within 3 days, if the service is scheduled 10 days out, you will receive a Good Faith Estimate with as much information possible. Some information required will be unavailable if you are a "New Client" never been seen by me.
Service CPT Codes and fees provided by TKR COUNSELING include:
90791 1.25 hour Initial Intake $120
90837 55-minute Individual Session $90
90847 55-minute family or couple session with client present $90
90846 55-minute family or couple session without client present $90
90839 30 - 74 minute crisis / emergency session $90
Services are not broken down into in-office or virtual due to the same CPT being used.
I have been assigned a National Provider Identifier (NPI number) that identifies me. It will be on the estimate.
The Employer Identification Number (EIN) for TKR Counseling Services PLLC is 87-240131
TKR Counseling Services is located at 1214 18th Street, Suite B1, Hondo, TX 78861
Separate good faith estimates will be issued to you upon request. You can request good faith estimates verbally during sessions or via your secure patient portal.
If there is an update to the charges for services, I will provide you a 30-day notice of the change of fee and provide options regarding continuing, transferring, or discontinuing services.
There may be additional items or services your provider recommends as part of psychotherapy that must be scheduled or requested separately and are not reflected in the good faith estimate;
The information provided in the good faith estimate is only an estimate regarding items or services reasonably expected to be furnished at the time the good faith estimate is issued to the uninsured (or self-pay) individual and that actual item, services, diagnosis or charges may differ from the good faith estimate; and
You have the right to initiate the patient-provider dispute resolution process if the actual billed charges are substantially in excess of the expected charges included in the good faith estimate, as specified in §149.620.
Dispute notices must be submitted to the U.S. Department of Health and Human Services (HHS).
The dispute process must be within 120 calendar days (about 4 months) of the date of the original bill.
There is a $25 fee to use the dispute process. If the agency reviewing your dispute agrees with you, you will have to pay the price on this Good Faith Estimate. If the agency disagrees with you and agrees with the health care provider or facility, you will have to pay the higher amount.
Keep a copy of this Good Faith Estimate in a safe place or take pictures of it. You may need it if you are billed a higher amount.
The initiation of the patient-provider dispute resolution process will not adversely affect the quality of health care services furnished to an uninsured (or self-pay) individual by a provider or facility; and
This good faith estimate is not a contract and does not require you to obtain the items or services from any of the providers or facilities identified in this good faith estimate.