Practice Policies

R.A.N. Counseling

APPOINTMENTS, CANCELLATION AND NO-SHOW POLICY

Appointments are scheduled in advance, at a cadence we agree on, based on your goals, treatment needs, and our mutual availability. We can schedule appointments on a recurring basis, you may schedule multiple appointments at a time, or you may choose to schedule on a session by session basis. Payments for each appointment will be made via Headway or Stripe for services rendered. Payment is due at the time of your regularly scheduled session.

I have a

48 hour cancellation policy.

For appointment no-shows or cancellations made within 48 hours of your session start time, you will be charged $100. This is necessary because a time commitment is made to you and is held exclusively for you, and I have a limited number of spots on my caseload. As long as I receive AT LEAST a 48 HOUR NOTICE, you may cancel appointments in advance without incurring the $100 cancellation fee. You can cancel by cancelling your appointment online, leaving me a voicemail at my confidential phone number 828 552 5260, or by emailing rose@rancounseling.com. (Texting is not a valid way to cancel the appointment, as I do not have the ability to send or receive texts from my office number).

3 cancellations or no-shows per year may result in a change in session frequency or being discharged from the Practice. Provider will provide referrals if discharge occurs.

The standard meeting time for psychotherapy is 53-55 minutes. It is up to you to determine if you’d like a shorter session. Requests to change the 53-55 minute session length will need to be discussed with me in advance.

LATE POLICY

I have a 15 minute grace period. If you arrive more than 15 minutes after your session start time, I will consider that a late cancellation and you will incur the $100 cancellation fee.

AVAILABILITY

I check for voice mail messages during normal business hours. Messages left outside of normal hours of operation will be picked up the next business day. You can leave a voicemail or send me an email to request, cancel, or reschedule your appointment. I do not send or receive text messages. I will make every attempt to inform you in advance of planned absences. If I need to cancel an appointment at the last-minute, I will reach out as soon as possible.

AFTER-HOURS EMERGENCIES

This is a non-crisis practice. My services are available by appointment only. I do not provide 24/7 coverage and may be in a session and unable to answer calls or respond to voicemails or emails immediately. If you are in crisis or need immediate assistance, please use the emergency resources provided below rather than attempting to contact me.

If you are experiencing suicidal or homicidal thoughts, are in crisis, or need immediate help, please call 911 or go to the nearest emergency department. Below are emergency phone numbers and mobile crisis information for the states R.A.N. Counseling serves:

Emergency Phone Numbers:

Text or call 988 for the Suicide & Crisis Lifeline (available 24/7) or 911

The National Suicide Prevention Lifeline is (800) 273-8255. The Lifeline provides 24/7, free and confidential support for people in distress and prevention and crisis resources for you or your loved ones.

LGBT National Hotline

1-888-843-4564

M - F, 1pm to 9pm, pacific time
(4pm to midnight, eastern time)

Sat, 9am to 2pm, pacific time
(noon to 5pm, eastern time)

North Carolina:

Mobile Crisis is available at (888) 573-1006

The NC Peer Warmline (1-855-PEERS-NC) is a free, private phone number you can call day or night to talk with someone who understands.

Mobile Crisis

Many times situations or crises occur that need an immediate response, but are not life-threatening. For these situations, North Carolina offers Mobile Crisis Management (MCM). MCM provides telephone and/or face-to-face assistance 24-hours a day, seven days a week. The mobile crisis team is composed of counselors who will meet you somewhere that you feel safe. Below are some mobile crisis numbers that you can call.

Buncombe County 888-573-1006

Forsyth County 866-275-9552

Franklin County 844-709-4097

Wake County 877-626-1772

Mecklenburg County Mobile Crisis Team

1-704-566-3410

Find a North Carolina Mobile Crisis Team

Behavioral health urgent care (BHUC) centers are an alternative to the emergency department for children and adults experiencing a mental health or substance use crisis. An individual can remain at the center for up to 23 hours and receive triage, crisis risk assessment, evaluation, and intervention for urgent or emergent needs. Below are BHUC centers at the following facilities:

The Smith Family Behavioral Health Urgent Care

Address

: 616 Colonnade Dr, Charlotte, NC 28205

Phone:

(704) 273-3942

Open 24 hours

Appalachian Community Services (NCG Acquisition) – The Balsam Center

, 91 Timberlane Rd., Waynesville, NC 28786

RHA Health Services – Alamance Behavioral Health Center,

963 Kirkpatrick Road, Burlington, NC 27215

RHA Health Services – Asheville C3 Comprehensive Care Center

, 356 Biltmore Ave., Asheville, NC 28801

RHA Health Services – Caldwell C3 Comprehensive Care Center

, 2415 Morganton Blvd. SW, Lenoir, NC 28645

Daymark Recovery Services – Rockingham County

, 355 County Home Road, Reidsville, NC 27320

North Carolina Hospitals/Emergency Rooms:

Located in: Mission Hospital

509 Biltmore Ave, Asheville, NC 28801

(828) 213-1111

South Asheville ER

2512 Hendersonville Rd, Arden, NC 28704

(828) 376-7111

Atrium Health Wake Forest Baptist Wake Forest Baptist Medical Center Emergency Department

1 Medical Center Blvd

Winston-Salem, NC 27157

(336) 716-9253

Located in: Novant Health Clemmons Medical Center

6915 Village Medical Cir, Clemmons, NC 27012

(336) 893-1000

Located in: Franklin Medical Center

100 Hospital Dr, Louisburg, NC 27549

(919) 340-8700

Atrium Health Carolinas Medical Center

1000 Blythe Blvd.

Charlotte, NC 28203

704-355-2000

District of Columbia:

Access HelpLine: 1-888-793-4357. Available 24/7

The Community Response Team offers 24-hour services to communities experiencing psychiatric emergencies, trauma, or show signs of mental health and substance use disorders.

To reach the Community Response Team any time call 202-673-6495 or visit:

35 K Street, NE Washington, DC 20002

DC Hospitals/Emergency Rooms:

Located in: MedStar Washington Hospital Center

110 Irving St NW, Washington, DC 20010

(202) 877-7000

Located in: George Washington University Hospital

Address: 900 23rd St NW, Washington, DC 20037

Phone: (202) 715-4000

Located in: Sibley Memorial Hospital

Address: 5255 Loughboro Rd NW, Washington, DC 20016

Phone: (202) 537-4080

Virginia:

For free, 24/7 mental health crisis support: You can call the Virginia Mental Health Hotline at 866-903-3787

Fairfax County:

Mobile Crisis Unit Hours

8 a.m. to 12 midnight daily

703-573-5679

Fax 703-876-1640 When the MCU is not able to respond, the Emergency Services staff at the Bulova Center is available for consultation and accepting MCU referrals.

Bulova Center

8221 Willow Oaks Corporate Drive Lower Level

Fairfax, Virginia 22031

24 Hour Service

703-573-5679

Arlington County:

Regional Crisis Call Center

703-527-4077 or text CONNECT to 855-11

24 hour mobile crisis response

Crisis Intervention Center:

The Crisis Intervention Center (CIC) provides behavioral healthcare services in a community-based setting to individuals experiencing a behavioral health crisis. The center is open 24 hours per day, seven days a week, to individuals of all ages experiencing a crisis. The CIC provides a warm, comfortable person-centered environment focused on recovery and wellness.

Phone: 703-228-5160

2120 Washington Blvd

Arlington VA 22204

Fredericksburg, VA:

Emergency Services: 540-373-6876

24 hours a day/ 7 days a week

Virginia Hospitals/Emergency rooms:

Located in: Inova Fairfax Medical Campus

Address: 3300 Gallows Rd, Falls Church, VA 22042

Phone: (703) 776-3116

Located in: Inova Alexandria Hospital

Address: 4320 Seminary Rd, Alexandria, VA 22304

Phone: (703) 504-3066

Located in: VHC Health - Virginia Hospital Center

Address: 1701 N George Mason Dr, Arlington, VA 22205

Phone: (703) 558-6168

Colorado:

WellPower Mental Health Services - Walk-in Crisis Center

4353 E Colfax Ave

Denver, CO 80220.

Phone: (844) 493-8255

Open 24 hours

Denver Hospitals/Emergency Rooms:

Located in: Denver Health

Address: 777 Bannock St Pavilion A, Denver, CO 80204

Phone: (303) 436-6000

ELECTRONIC COMMUNICATION and TELEHEALTH CONSENT: I give the provider permission to contact me via e-mail, phone and mail via the contact information on my intake form. I agree to receive automated text and email message reminders of appointments at the phone number on my intake form.I cannot ensure the confidentiality of any form of communication through electronic media. If you prefer to communicate via email for issues regarding scheduling or cancellations, I will do so. While I may try to return messages in a timely manner, I cannot guarantee immediate response and request that you do not use these methods of communication to discuss therapeutic content and/or request assistance for emergencies.

PUBLIC INSURANCE RIGHTS: In the case that a patient has public insurance (Medicaid or Medicare), they understand that R.A.N. Counseling PLLC does not accept these types of insurance. I understand that I have the right to find and use a provider that does accept this insurance at any time.

THERAPEUTIC FOCUS

Our practice is dedicated to providing clinical diagnosis and treatment. We do not offer services for the completion of letters, forms, or any other documentation for external entities (e.g., employers, schools, disability claims, court proceedings, emotional support animal certification). This boundary is essential to maintain the focus and integrity of our therapeutic relationship and ensure consistency across all clients.

COURT: R.A.N. Counseling PLLC does not make court appearances. They do not assist clients in divorce or custody litigation, writing court reports, making recommendations to the court, or testifying for or against clients in a court of law.

DISCHARGE PROCESS

Ending a therapeutic relationship can be difficult, and “graduating” from therapy is best discussed throughout the treatment process. It is important to have a termination process in order to achieve some closure. There are several reasons why we may eventually end our professional relationship. You may decide you would prefer to work with a different provider. I may reach the conclusion you would be better served working with someone else, I may determine that psychotherapy is not being effectively used, or if you are in default on payment. I will not terminate the therapeutic relationship without first discussing and exploring the reasons and purpose of terminating. I will also extend the discharge process length if necessary based on your treatment needs, including continuing to provide emergency support for a time-limited period after you have been notified of the end of our treatment relationship. If therapy is terminated for any reason or you request another therapist, I will provide you with a list of qualified psychotherapists. You may also choose someone on your own or from another referral source.

Should you fail to schedule an appointment for three consecutive weeks, unless other arrangements have been made in advance, for legal and ethical reasons, I must consider the professional relationship discontinued.

Please note that ongoing failure to pay for treatment, attend sessions, or communicate with me in a respectful and timely manner can also result in discharge from my practice. In addition, any patient who engages in inappropriate behavior in the office will immediately be terminated as a client. In these instances, to ensure you have continued access to care, I will still make every reasonable effort to get in touch with you and provide referrals to a new provider before I consider our relationship ended.

R.A.N. Counseling PLLC

INFORMED CONSENT

About psychotherapy services

Psychotherapy is a working cooperative relationship between you and your therapist. Each member of this cooperative relationship has certain responsibilities. Your therapist will contribute their knowledge, expertise, and clinical skills. You, as the client, have the responsibility to bring an attitude of collaboration and a commitment to the therapeutic process. While there are no guarantees regarding the outcome of the treatment, your commitment may increase the likelihood of a satisfactory experience.

As a client in psychotherapy, you have certain rights and responsibilities that are important for you to understand. There are also legal limitations to those rights that you should be aware of. I, as your therapist, have corresponding responsibilities to you. These rights and responsibilities are described in the following sections.

Please note that psychotherapy is not an emergency service. If you are experiencing suicidal or homicidal thoughts, are in crisis, or need immediate help, please call 911 or go to the nearest emergency department.

Benefits and risks of psychotherapy

Psychotherapy has both benefits and risks. Risks may include experiencing uncomfortable feelings, such as sadness, guilt, anxiety, anger, frustration, loneliness and helplessness, because the process of psychotherapy often requires discussing the unpleasant aspects of your life. However, psychotherapy has been shown to have benefits for individuals who undertake it. Therapy often leads to a significant reduction in feelings of distress, increased satisfaction in interpersonal relationships, greater personal awareness and insight, increased skills for managing stress and resolutions to specific problems.

Note that there are no guarantees about what will happen. Psychotherapy requires a very active effort on your part. In order to be most successful, you will have to work on things we discuss outside of sessions.

The first few sessions

The first few sessions typically involve a comprehensive evaluation of your needs. By the end of the evaluation, I will be able to offer you some initial impressions of what our work might include. At that point, we will discuss your treatment goals and create an initial treatment plan. You should evaluate this information and make your own assessment about whether you feel comfortable working with me. If you have questions about my procedures, we should discuss them whenever they arise. If your doubts persist, I will be happy to help you set up a meeting with another mental health professional for a second opinion.

Appointments and cancellations

Appointments are typically held at the same time each week, at a cadence we agree on (such as weekly or every other week). Payments for each appointment can be made through Headway by debit or credit card or ACH transfer.

You may cancel appointments in advance free of charge, as long as I receive notice far enough in advance. For appointment no-shows or last-minute cancellations, you will be charged a fee. Please reach out to me directly for my latest policy on the cancellation cutoff period and fees.

Professional Records

I am required to keep appropriate records of the psychological services that I provide. I keep brief records noting that you were here, your reasons for seeking therapy, the goals and progress we set for treatment, your diagnosis, topics we discussed, your medical, social, and treatment history, records I receive from other providers, copies of records I send to others, and your billing records. Except in unusual circumstances that involve danger to yourself, you have the right to a copy of your file. Because these are professional records, they may be misinterpreted and / or upsetting to untrained readers. For this reason, I recommend that you initially review them with me, or have them forwarded to another mental health professional to discuss the contents. If I refuse your request for access to your records, you have a right to have my decision reviewed by another mental health professional, which I will discuss with you upon your request. You also have the right to request that a copy of your file be made available to any other health care provider at your written request.

Confidentiality

Communication between you and your counselor is confidential. This means that your counselor will not discuss your case orally or in writing without your expressed written permission.Your counselor has an ethical and legal obligation to break confidentiality under the following circumstances:

If there is a reason to believe there is an occurrence of child, elder, or dependent adult abuse or neglect.
If there is reason to believe that you have serious intent to harm yourself, someone else, or property by a violent act you may commit.
If you disclose that you knowingly develop, duplicate, print, download, stream, or access through any electronic or digital media or exchanges, a film, photograph, video in which a child is engaged in an act of obscene sexual conduct.
If you introduce your emotional condition into a legal proceeding.
If there is a court order for release of your records.

Additional Rights and Responsibilities

In addition to your right to confidentiality, you have the right to end your counseling at any time, for whatever reason and without any obligation, with the exception of payment of fees for services already provided. You have the right to question any aspect of your treatment with your therapist.

You also have the right to expect that your therapist will maintain professional and ethical boundaries by not entering into other personal, financial, or professional relationships with you.
If you are unhappy with what is happening in therapy, I hope you will talk with me so that I can respond to your concerns. Such comments will be taken seriously and handled with care and respect. You may also request that I refer you to another therapist.
You have the right to considerate, safe and respectful care, without discrimination as to race, ethnicity, color, gender, sexual orientation, age, religion, or national origin.
You have the right to ask questions about any aspects of therapy and about my specific training and experience.
In circumstances that lead me to conclude that your counseling needs would be better served at another counseling facility, I will suggest an appropriate counselor(s) or counseling agency.
Your signature below indicates that you have read and understand this information and have received a copy of this consent form and give permission to us to provide counseling services and that this contract is binding for all future sessions you may have with this entity.

R.A.N. Counseling PLLC

NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW YOUR HEALTH INFORMATION MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. YOU MAY HAVE ADDITIONAL RIGHTS UNDER STATE AND LOCAL LAW. PLEASE SEEK LEGAL COUNSEL FROM AN ATTORNEY LICENSED IN YOUR STATE IF YOU HAVE QUESTIONS REGARDING YOUR RIGHTS TO HEALTH CARE INFORMATION.

EFFECTIVE DATE OF THIS NOTICE

This notice went into effect on 1/1/2023

ACKNOWLEDGEMENT OF RECEIPT OF PRIVACY NOTICE

Under the Health Insurance Portability and Accountability Act of 1996 (hereafter, “HIPAA”), you have certain rights regarding the use and disclosure of your protected health information (hereafter, “PHI”).

I. MY PLEDGE REGARDING HEALTH INFORMATION:

I understand that health information about you and your health care is personal. I am committed to protecting health information about you. I create a record of the care and services you receive from me. I need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by this mental health care practice. This notice will tell you about the ways in which I may use and disclose health information about you. I also describe your rights to the health information I keep about you, and describe certain obligations I have regarding the use and disclosure of your health information.

I am required by law to:

Make sure that PHI that identifies you is kept private.
Give you this notice of my legal duties and privacy practices with respect to health information.
Follow the terms of the notice that is currently in effect.
I can change the terms of this Notice, and such changes will apply to all the information I have about you. The new Notice will be available upon request, in my office, and on my website.

II. HOW I MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU:

The following categories describe different ways that I use and disclose health information. For each category of uses or disclosures I will explain what I mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways I am permitted to use and disclose information will fall within one of the categories.

For Treatment Payment, or Health Care Operations: Federal privacy rules (regulations) allow health care providers who have direct treatment relationship with the patient/client to use or disclose the patient/client’s personal health information without the patient’s written authorization, to carry out the health care provider’s own treatment, payment or health care operations. I may also disclose your PHI for the treatment activities of any health care provider. This too can be done without your written authorization. For example, if a clinician were to consult with another licensed health care provider about your condition, we would be permitted to use and disclose your PHI, which is otherwise confidential, in order to assist the clinician in diagnosis and treatment of your health condition. I may also use your PHI for operations purposes, including sending you appointment reminders, billing invoices and other documentation.

Disclosures for treatment purposes are not limited to the minimum necessary standard. Because therapists and other health care providers need access to the full record and/or full and complete information in order to provide quality care. The word “treatment” includes, among other things, the coordination and management of health care providers with a third party, consultations between health care providers and referrals of a patient for health care from one health care provider to another.

Lawsuits and Disputes: If you are involved in a lawsuit, I may disclose health information in response to a court or administrative order. I may also disclose health information about you or your minor child(ren) in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.

III. CERTAIN USES AND DISCLOSURES REQUIRE YOUR AUTHORIZATION:

Psychotherapy Notes. I do keep “psychotherapy notes” as that term is defined in 45 CFR § 164.501, and any use or disclosure of such notes requires your Authorization unless the use or disclosure is:
1. For my use in treating you.
2. For my use in training or supervising mental health practitioners to help them improve their skills in group, joint, family, or individual counseling or therapy.
3. For my use in defending myself in legal proceedings instituted by you.
4. For use by the Secretary of the Department of Health and Human Services (HHS) to investigate my compliance with HIPAA.
5. Required by law and the use or disclosure is limited to the requirements of such law.
6. Required by law for certain health oversight activities pertaining to the originator of the psychotherapy notes.
7. Required by a coroner who is performing duties authorized by law.
8. Required to help avert a serious threat to the health and safety of others.
Marketing Purposes. I will not use or disclose your PHI for marketing purposes without your prior written consent. For example, if I request a review from you and plan to share the review publicaly online or elsewhere to advertise my services or my practice, I will provide you with a release form and HIPAA authorization. The HIPAA authorization is required in the instance that your review contains PHI (i.e., your name, the date of the service you received, the kind of treatment you are seeking or other personal health details). Because you may not realize which information you provide is considered “PHI,” I will send you a HIPAA authorization and request your signature regardless of the content of your review. Once you complete the HIPAA authorization, I will have the legal right to use your review for advertising and marketing purposes, even if it contains PHI. You may withdraw this consent at any time by submitting a written request to me via the email address I keep on file or via certified mail to my address. Once I have received your written withdrawal of consent, I will remove your review from my website and from any other places where I have posted it. I cannot guarantee that others who may have copied your review from my website or from other locations will also remove the review. This is a risk that I want you to be aware of, should you give me permission to post your review.
Sale of PHI. I will not sell your PHI.

IV. USES AND DISCLOSURES THAT DO NOT REQUIRE YOUR AUTHORIZATION.

Subject to certain limitations in the law, I can use and disclose your PHI without your Authorization for the following reasons. I have to meet certain legal conditions before I can share your information for these purposes:

Appointment reminders and health related benefits or services. I may use and disclose your PHI to contact you to remind you that you have an appointment with me. I may also use and disclose your PHI to tell you about treatment alternatives, or other health care services or benefits that I offer.
When disclosure is required by state or federal law, and the use or disclosure complies with and is limited to the relevant requirements of such law.
For public health activities, including reporting suspected child, elder, or dependent adult abuse, or preventing or reducing a serious threat to anyone’s health or safety.
For health oversight activities, including audits and investigations.
For judicial and administrative proceedings, including responding to a court or administrative order or subpoena, although my preference is to obtain an Authorization from you before doing so if I am so allowed by the court or administrative officials.
For law enforcement purposes, including reporting crimes occurring on my premises.
To coroners or medical examiners, when such individuals are performing duties authorized by law.
For research purposes, including studying and comparing the mental health of patients who received one form of therapy versus those who received another form of therapy for the same condition.
Specialized government functions, including, ensuring the proper execution of military missions; protecting the President of the United States; conducting intelligence or counterintelligence operations; or, helping to ensure the safety of those working within or housed in correctional institutions.
For workers’ compensation purposes. Although my preference is to obtain an Authorization from you, I may provide your PHI in order to comply with workers’ compensation laws.
For organ and tissue donation requests.

V. CERTAIN USES AND DISCLOSURES REQUIRE YOU TO HAVE THE OPPORTUNITY TO OBJECT.

Disclosures to family, friends, or others: You have the right and choice to tell me that I may provide your PHI to a family member, friend, or other person whom you indicate is involved in your care or the payment for your health care, or to share you information in a disaster relief situation. The opportunity to consent may be obtained retroactively in emergency situations to mitigate a serious and immediate threat to health or safety or if you are unconscious.

VI. YOU HAVE THE FOLLOWING RIGHTS WITH RESPECT TO YOUR PHI:

The Right to Request Limits on Uses and Disclosures of Your PHI. You have the right to ask me not to use or disclose certain PHI for treatment, payment, or health care operations purposes. I am not required to agree to your request, and I may say “no” if I believe it would affect your health care.
The Right to Request Restrictions for Out-of-Pocket Expenses Paid for In Full. You have the right to request restrictions on the disclosure of your PHI to health plans for payment or health care operations purposes if the PHI pertains solely to a health care item or a health care service that you have paid for out-of-pocket in full.
The Right to Choose How I Send PHI to You. You have the right to ask me to contact you in a specific way (for example, home or office phone) or to send mail to a different address, and I will agree to all reasonable requests.
The Right to See and Get Copies of Your PHI. Other than in limited circumstances, you have the right to get an electronic or paper copy of your medical record and other information that I have about you. Ask us how to do this. I will provide you with a copy of your record, or if you agree, a summary of it, within 30 days of receiving your written request. I may charge a reasonable cost based fee for doing so.
The Right to Get a List of the Disclosures I Have Made.You have the right to request a list of instances in which I have disclosed your PHI for purposes other than treatment, payment, or health care operations, ans other disclosures (such as any you ask me to make). Ask me how to do this. I will respond to your request for an accounting of disclosures within 60 days of receiving your request. The list I will give you will include disclosures made in the last six years unless you request a shorter time. I will provide the list to you at no charge, but if you make more than one request in the same year, I will charge you a reasonable cost based fee for each additional request.
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 from your PHI, you have the right to request that I correct the existing information or add the missing information. I may say “no” to your request, but I will tell you why in writing within 60 days of receiving your request.
The Right to Get a Paper or Electronic Copy of this Notice. You have the right to get a paper copy of this Notice, and you have the right to get a copy of this notice by email. And, even if you have agreed to receive this Notice via email, you also have the right to request a paper copy of it.
The Right to 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 make choices about your health information.
The Right to Revoke an Authorization.
The Right to Opt out of Communications and Fundraising from our Organization.
The Right to File a Complaint. You can file a complaint if you feel I have violated your rights by contacting me using the information on page one or by filing a complaint with the HHS Office for Civil Rights located at 200 Independence Avenue, S.W., Washington D.C. 20201, calling HHS at (877) 696-6775, or by visiting www.hhs.gov/ocr/privacy/hipaa/complaints. I will not retaliate against you for filing a complaint.

VII. CHANGES TO THIS NOTICE

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

No Surprises Act

You have the right to receive a Good Faith Estimate of what your services may cost.