“Right to Receive a Good Faith Estimate of Expected Charges” Under the No Surprises Act

You have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost

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, visit www.cms.gov/nosurprises or call 720.515.7360.    

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:
• Cover emergency services without requiring you to get approval for services in advance (prior authorization).
• Cover emergency services by out-of-network providers.
• 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.
• 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,  please contact: Sara Karlich at 406.637.6395. Or, you may contact the  Montana Division of Insurance at 406.444.2040, Texas Department of Insurance at 800-578-4677, or Utah Insurance Department 801-957-9200.
 

Visit https://www.cms.gov/files/document/model-disclosure-notice-patient-protections-against-surprise-billing-providers-facilities-health.pdf for more information about your rights under Federal law.

Protected Health Information (PHI):  PHI is information that identifies who you are and relates to your  past, present, or future physical or mental health condition, the  provision of health care to you, or a past, present, or future payment  for provision of health care to you.
 

Please note that I reserve  the right to change the terms of this Notice and my privacy policies at  any time.  Any changes will apply to PHI already on file with me.   Before I make any important changes to my policies, I will immediately  change this Notice and post a new copy of it in my office.  You may also  request a copy of this Notice from me, or you can view a copy of it in  my office.
 

How we protect your PHI: Access to  your PHI is limited to those employees who have a need to use the  information for billing, administrative or similar purposes, or who  become involved with an issue regarding your health or a claim on your  behalf.  We maintain appropriate physical, electronic, and procedural  safeguards to protect your PHI against unauthorized use or disclosure.
 

Types of uses and disclosures of PHI we may make without your authorization
 

1. Treatment  - We may disclose your PHI to physicians, psychiatrists, psychologists,  and other licensed health care providers who provide you with health  care services or are otherwise involved in your care.  Example:  If a  psychiatrist is treating you, we may disclose your PHI to her/him in  order to coordinate your care.
2. Payment – We may use and  disclose your PHI to bill and collect payment for the treatment and  services we have provided you.  Example: We might send your PHI to your  insurance company or health plan in order to get payment for the health  care services that we have provided to you.  We could also provide your  PHI to business associated, such as billing companies, claims processing  companies and others that process health care claims for my office. 
3. Health  Care Operations - We may disclose your PHI to facilitate the efficient  and correct operation of our practice.  Examples:  Quality control – We  might use your PHI in the evaluation of the quality of health care  services that you have received or to evaluate the performance of the  health care professionals who provided you with these services.  We may  also provide your PHI to my attorneys, accountants, consultants, and  others to make sure that we am in compliance with applicable laws.

Sara Karlich is also allowed to use and disclose your PHI without your consent or authorization for the following purposes:
 

• When  disclosure is required by federal, state, or local law; judicial,  board, or administrative proceedings; or, law enforcement.
• If disclosure is compelled by a party to a proceeding before a court pursuant to its lawful authority. 
• If disclosure is required by a search warrant lawful issued to a governmental law enforcement agency.
• If  disclosure is compelled by the client or the client’s representative  pursuant to state or federal statutes or regulations, such as the  Privacy Rule that requires this Notice.
• To avoid harm. We may  provide PHI to law enforcement personnel or persons able to prevent or  mitigate a serious threat to the health or safety of a person or the  public.
• If disclosure is compelled or permitted by the fact that  you are in such mental or emotional condition as to be dangerous to  yourself or the person or property of others, and if I determine that  disclosure is necessary to prevent the threatened danger.
• If disclosure is mandated by the Montana, Texas, or Utah law.
• If disclosure is mandated by the Montana, Texas, or Utah Elder/Dependent Adult Abuse Reporting law.
• If  disclosure is compelled or permitted by the fact that you tell me of a  serious/imminent threat of physical violence by you against a reasonably  identifiable victim or victims.
• For public health activities.  Example: In the event of your death, if a disclosure is permitted or  compelled, we may need to give the county coroner information about you.
• For health oversight activities. 
• For specific government functions. 
• For research purposes. In certain circumstances, I may provide PHI in order to conduct medical research.
• For Workers’ Compensation purposes. I may provide PHI in order to comply with Workers’ Compensation laws.
• Appointment  reminders and health related benefits or services.  Examples: we may  use PHI to provide appointment reminders.  We may use PHI to give you  information about alternative treatment options, or other health care  services or benefits we offer.
• If an arbitrator or arbitration  panel compels disclosure, when arbitration is lawfully requested by  either party, pursuant to subpoena duces tectum (e.g., a  subpoena for mental health records) or any other provision authorizing  disclosure in a proceeding before an arbitrator or arbitration panel.
• I  am permitted to contact you, without your prior authorization, to  provide appointment reminders or information about alternative or other health-related benefits and services that may be of interest to you.
• If disclosure is required or permitted to a health oversight agency for oversight activities authorized by law. 
• If disclosure is otherwise specifically required by law.

​Authorizations
All  other uses and disclosures of your PHI will be made by Sara Karlich only  with your written authorization.  You may revoke your authorization at  any time in writing.
 

Your rights concerning your PHI

1. Access  to your personal information – As a matter of federal and state law,  you have the right to review and copy your PHI that is in our  possession.  If you desire access to your PHI, you must notify Sara Karlich in writing.  She will respond to your request within 30 days.  If  you request a copy of your PHI, a copy may be provided.  A reasonable  fee for copying will be charged.  However, under federal law, you may  not inspect psychotherapy notes or information compiled in reasonable  anticipation of, or use in, a civil, criminal, or administration  proceeding.
2. Right to request restrictions – You have the  right to request a restriction on how we use and disclose your PHI.  All  requests must be made in writing.  Upon receipt, we will review your  request and notify you whether we have accepted or denied your request.   Please note that we are not required to grant your request.  If we do  agree to your request, we put those restrictions in writing and abide by  them except in emergency situations. 
3. Right to amend your PHI –  If you believe that there is some error in your PHI or that important  information has been omitted, it is your right to request that I correct  the existing information or add the missing information. Your request  and the reason for the request must be made in writing.  You will  receive a response within 60 days of our receipt of your request.  We  may deny your request, in writing, if we find that:  the PHI is (a)  correct and complete, (b) forbidden to be disclosed, (c) not part of our  records, or (d) written by someone other than LRG personnel.  Our  denial must be in writing and must state the reasons for the denial.  It  must also explain your right to file a written statement objecting to  the denial.  If you do not file a written objection, you still have the  right to ask that your request and my denial be attached to any future  disclosures of your PHI.  If we approve your request, we will make the  change(s) to your PHI.  Additionally, we will inform you that the  changes have been made, and we will advise all others who need to know  about the change(s) to your PHI.
4. Right to request  confidential communications – You have the right to request that we  communicate with you about your PHI matters in a certain and at a  certain location.  Example: You may request that we communicate with you  by sealed envelope rather than post card or calling you at work.  
5. Right  to get a list of disclosures – You are entitled to a list of  disclosures of your PHI that we have made.  The list will not include  uses or disclosures to which you have already consented, i.e., those for  treatment, payment, or health care operations, sent directly to you, or  to your family.  Neither will the list include disclosures made for  national security purposes, to corrections or law enforcement personnel,  or disclosures made before April 1 2021.  After April 1, 2021 ,  disclosure records will be held for six years.
6. 
   

Right to Complain
You  will not be penalized for filing a complaint. If you believe your  privacy rights have been violated, you may file a complaint in writing  to:
 

Sara Karlich
6479 US Highway 93 #1010
Whitefish, MT 59937
 

You may also notify the Secretary of the Department of Health and Human Services.
 

The effective date of this Notice is August 25, 2012

NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

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 protected health information (“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 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 protected health information 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 person health information, which is otherwise confidential, in order to assist the clinician in diagnosis and treatment of your mental health condition.

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 your child 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 and Coaching 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:

a. For my use in treating you.

b. 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.

c. For my use in defending myself in legal proceedings instituted by you.

d. For use by the Secretary of Health and Human Services to investigate my compliance with HIPAA.

e. Required by law and the use or disclosure is limited to the requirements of such law.

f. Required by law for certain health oversight activities pertaining to the originator of the psychotherapy and coaching notes.

g. Required by a coroner who is performing duties authorized by law.

h. Required to help avert a serious threat to the health and safety of others.

Marketing Purposes. As a psychotherapist and coach, I will not use or disclose your PHI for marketing purposes.

Sale of PHI. As a psychotherapist and coach, I will not sell your PHI in the regular course of my business.

IV. CERTAIN USES AND DISCLOSURES 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:

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, although my preference is to obtain an Authorization from you before doing so.

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 counter-intelligence 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.

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.

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

Disclosures to family, friends, or others. I may provide your PHI to a family member, friend, or other person 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.

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 disclosures 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 “psychotherapy notes,” you have the right to get an electronic or paper copy of your medical record and other information that I have about you. I will provide you with a copy of your record, or a summary of it, if you agree to receive a summary, within 30 days of receiving your written request, and 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, or for which you provided me with an Authorization. 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 get a paper copy of this Notice, and you have the right to get a copy of this notice by e-mail. And, even if you have agreed to receive this Notice via e-mail, you also have the right to request a paper copy of it.

EFFECTIVE DATE OF THIS NOTICE

This notice went into effect on 07/08/2025

Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), you have certain rights regarding the use and disclosure of your protected health information. By agreeing to this form, you are acknowledging that you have received a copy of HIPAA Notice of Privacy Practices.

Messaging Terms & Conditions:

You agree to receive informational messages (appointment reminders, account notifications, etc.) from [Company name]. Message frequency varies. Message and data rates may apply. For help, replyHELP or email us at [Company general email address]. You can optout at any time by replying STOP.  

Mobile SMS Messaging Privacy Policy:

Information collected:

We may collect information, such as name, phone number, and email address. 

Use of information collected:

We may use the information we collect to perform the services requested including billing, customer service, appointment reminders and other administrative requests.

Sharing of information collected:

We may share information we collect with payment processors, legal authorities, partners so that these service providers can perform their normal duties. We do not share, sell, rent, or trade any information provided with third parties for promotional purposes.

As a current or prospective customer, you understand that you can text us STOP at any time to opt out of receiving SMS text messages from us. You can text us HELP at any time to receive help.

You understand that the messaging frequency may vary. Messaging & data rates may apply.

‍Your mobile information will not be shared with any third parties/affiliates for marketing/promotional purposes. All policies are followed as per CTIA guidelines 5.2.1. At any time if you want your information to be removed, you can contact us via our email address or regular mail.  

Clients have the right to request access to their health care records.

To request your records:

1. Submit a written request by email or through the secure client portal.
2. Include your full name, date of birth, and the specific records you are requesting.
3. Requests may be subject to identity verification and applicable fees as permitted by law.
4. Records will be provided within the timeframe required by Texas law.

If you have questions about requesting records, please contact the practice directly using the contact information listed on this website.

If you would like to contact the Texas Behavioral Health Executive Council (BHEC), which oversees behavioral health licensing boards in Texas, you may do so using the information below:

Texas Behavioral Health Executive Council
Website: https://www.bhec.texas.gov
Contact Page: https://www.bhec.texas.gov/contact-us

The Council can provide information about licensure, regulations, and the complaint process.

If you believe your rights have been violated or you wish to file a consumer complaint, you may contact the Office of the Texas Attorney General’s Consumer Protection Division.

You can file a complaint online at:
https://www.texasattorneygeneral.gov/consumer-protection/file-consumer-complaint

This process is independent of the practice and allows consumers to raise concerns related to services provided in Texas.

These disclosures are provided in accordance with Texas House Bill 4224 and Texas Health & Safety Code §181.105.