“No Surprises” Act
Effective January 1, 2022, laws regulating client care have been updated to include the “No Surprises” act, which requires a wide variety of providers to give current and potential future clients a “Good Faith Estimate” (GFE) on the cost of treatment. Below you will find a summary of this requirement.

Effective January 1, 2022, a provider must furnish a self-pay patient with the notice and GFE prior to all scheduled services or by request if the patient is shopping for care (and not yet at the point of scheduling). This includes, but is not limited to, office visits, therapy, diagnostic tests, infusions, and surgeries.

Who qualifies as a self-pay patient?
A providerʼs duty to provide notice and a GFE applies to self-pay patients, i.e., an individual who (1) does not have benefits for an item or service under a group health plan, group or individual health insurance coverage offered by a health insurance issuer, federal healthcare program, or a health benefits plan; or (2) chooses not to use his or her coverage benefit for the item or service.

In many ways, this protects patients from discovering that they owe a massive medical bill for un-covered services after the fact. However, therapy is a little different in that we canʼt necessarily provide an estimate of how long it takes to complete a treatment plan. There are a number of variables that make it nearly impossible to quantify what will be needed. And there is no way to give a “good faith estimate” on whether or not a client will want to return for services later on.

Good Faith Estimate Details:
New clients are required to begin with 1 hour intake appointment. Future appointments are scheduled on an as needed basis depending on client preference (i.e. weekly, biweekly, monthly). There is a sliding scale for qualifying clients as well. This is subject to change with notice.

Licensed Therapist (LPC):
Intake appointment $125
Follow up (50min)sessions $125
Client sees therapist weekly for 50 weeks in calendar year $ 6,250

The frequency with which clients are seen, and the duration of time in which they are seen, is dependent on client need. These figures are providing a good faith estimate based on typical scheduling requests. The above examples are for illustrative purposes only and are not specific to you or your treatment. Instead they are meant to show the possible variation of cost that could occur within a given year.

Notice of Privacy Practices (NPP)

Your Information. Your Rights. Our Responsibilities.

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.

Your Rights

You have the right to:

• Get a copy of your paper or electronic medical record

• Correct your paper or electronic medical record

• Request confidential communication

• Ask me to limit the information I share

• Get a list of those with whom I’ve shared your information

• Get a copy of this privacy notice

• Choose someone to act for you

• File a complaint if you believe your privacy rights have been violated

Your Choices

You have some choices in the way that I use and share information as I:

• Tell family and friends about your condition

• Provide mental health care

My Uses and Disclosures

I may use and share your information as I:

• Treat you

• Run my business

• Bill for your services

• Comply with the law

Your Rights

When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.

Get an electronic or paper copy of your medical record

• You can ask to see or get an electronic or paper copy of your medical record and other health information I have about you. Ask me how to do this.

• I will provide a copy or a summary of your health information, usually within 30 days of your request.

Ask me to correct your medical record

• You can ask me to correct health information about you that you think is incorrect or incomplete. Ask me how to do this.

• I may say “no” to your request, but we’ll tell you why in writing within 60 days.

Request confidential communications

• You can ask me to contact you in a specific way (for example, home or office phone) or to send mail to a different address.

• I will say “yes” to all reasonable requests.

Ask me to limit what I use or share

• You can ask me not to use or share certain health information for treatment, payment, or my operations. I am not required to agree to your request, and I may say “no” if it would affect your care.

• If you pay for a service or health care item out-of-pocket in full, you can ask me not to share that information for the purpose of payment or my operations with your health insurer. I will say “yes” unless a law requires me to share that information.

Get a list of those with whom we’ve shared information

• You can ask for a list (accounting) of the times I’ve shared your health information for six years prior to the date you ask, who I shared it with, and why.

• I will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked me to make). I’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.

Get a copy of this privacy notice

• You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. I will provide you with a paper copy promptly.

Choose someone to act for you

• If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.

• I will make sure the person has this authority and can act for you before I take any action.

File a complaint if you feel your rights are violated

• You can complain if you feel I have violated your rights by contacting me using the information in this form.

• You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting

www.hhs.gov/ocr/privacy/hipaa/complaints/.

• I will not retaliate against you for filing a complaint.

Your Choices

For certain health information, you can tell me your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to me. Tell me what you want me to do, and I will follow your instructions.

In these cases, you have both the right and choice to tell me to:

• Share information with your family, close friends, or others involved in your care

• Most sharing of psychotherapy notes

My Uses and Disclosures

How do I typically use or share your health information?

I typically use or share your health information in the following ways.

Treat you

I can use your health information and share it with other professionals who are treating you.

Run my business

I can use and share your health information to run my practice, improve your care, and contact you when necessary.

Example: I use health information about you to manage your treatment and services.

Bill for your services

I can use and share your health information to bill and get payment from health plans or other entities.

Example: I give information about you to your health insurance plan so it will pay for your services.

How else can I use or share your health information?

I am allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. I must meet many conditions in the law before I can share your information for these purposes. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.

I will share information about you if state or federal laws require it, including with the

Department of Health and Human Services if it wants to see that we’re complying with federal privacy law.

I can use or share health information about you:

I can share health information about you in response to a court or administrative order, or in response to a subpoena.

My Responsibilities

• I am required by law to maintain the privacy and security of your protected health information.

• I will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.

• I must follow the duties and privacy practices described in this notice and give you a copy of it if requested.

• I will not use or share your information other than as described here unless you tell us I can in writing. If you tell me I can, you may change your mind at any time. Let me know in writing if you change your mind.

For more information see:

www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.

Changes to the Terms of this Notice

I can change the terms of this notice, and the changes will apply to all information I have about you. The new notice will be available upon request, in my office, and on my website.

Other Information:

• Effective date: 10/28/2025

• Privacy Official:

Amie Hope Thomas

amie@hopehealingenergy.com

475-318-0929

Complaints

You also may file a complaint with the Secretary of the U.S. Department of Health and Human Services. Complaints filed directly with the Secretary must (1) be in writing; (2) contain the name of the entity against which the complaint is lodged; (3) describe the relevant problems; and (4) be filed within 180 days of the time you became or should have become aware of the problem. The mailing address is: Secretary of the Department of Health and Human Services, Office for Civil Rights, U.S. Department of Health and Human Services, Room 509F, HHH Building, 200 Independence Avenue, SW, Washington, DC 20201.

The phone number is 1-800- 368-1019. The e-mail address is ocrprivacy@hhs.gov or visit the website at www.hhs.gov/ocr/privacy/hipaa/complaints/.

You will not be penalized or otherwise retaliated against for filing such a complaint.