Flourish Wellness, PLLC is committed to protecting your privacy. To better protect your privacy we provide this notice explaining our online information practices. To make this notice easy to find, we make it available on our website.
1. INFORMATION COLLECTION AND USE
We collect information about visitors to our Site so that we can provide an experience that is responsive to our users' and customers' needs. We do not collect medical information or credit card information through our Site. Our Site may use forms in which you give us contact information (including your name, address, telephone number, and email address) so you can request information or support. We receive and store any information you enter on our Site, or give us in any other way, including through email, telephone, or other communications within our customer services department. You do not need to give us any personal information in order to use our Site.
We will not sell, share, trade or otherwise use any information you provide unless you expressly provide in writing permission for such use. We collect this information to improve our service, and to help us determine your individual needs so we may serve you better individually, as well as collectively.
We will not sell, share, trade or otherwise use any medical information under any circumstances. If you require medical information, you must request it from us directly via a Medical Release form.
We may also collect non-personally identifiable information about you, such as your use of our web sites, communication preferences, aggregated data relative to your Services, and responses to promotional offers and surveys. We may use or disclose aggregate information only where no individual is identified for a number of purposes, including: (a) Compiling aggregate statistics of usage for improving the web site; (b) Developing, maintaining and administering the web site; and (c) Following up on comments and other messages that you submit to us through the web site.
Please note, to better safeguard your information, please do not include any credit card information in your electronic communication unless it is specifically required by us as part of Services or transaction fulfillment process sites, or our customer contact process.
This Site and our Services may contain links to other websites. Unfortunately, we are not responsible for the privacy practices or the content of such sites.
This Site has security measures in place to protect against the loss, misuse or alteration of the information under our control. If our site allows you to enter sensitive information (such as a credit card number) on order firms, we encrypt the transmission of that information using secure socket layer technology (SSL).
We may also at times provide information about you to third parties to provide various services on our behalf, such as providers who process credit card payments. We will only share information about you that is necessary for the third party to provide the requested service. These companies are prohibited from retaining, sharing, buying, selling, storing or using your personally identifiable information for any secondary purposes.
We follow generally accepted standards to protect the personal information submitted to us, both during transmission and once we receive it. No method of transmission over the Internet, or method of electronic storage, is one hundred percent (100%) secure, however. Therefore, we cannot guarantee its absolute security.
1. GOOGLE ANALYTICS AND COOKIES
We may use a tool called “Google Analytics” to collect information about use of this Site, such as how often users visit the Site, what pages they visit when they do so, and what other sites they used prior to coming to this Site. Google Analytics collects only the IP address assigned to you on the date you visit this Site, rather than your name or other identifying information.
Google Analytics plants a permanent cookie on your web browser to identify you as a unique user the next time you visit this Site. This cookie cannot be used by anyone but Google, Inc. The information generated by the cookie will be transmitted to and stored by Google on servers in the United States.
We use the information received from Google Analytics only to improve services on this Site. We do not combine the information collected through the use of Google Analytics with personally identifiable information.
1. COLLECTION AND USE OF PERSONAL INFORMATION OF CHILDREN UNDER AGE 13
We are committed to protecting the online privacy of children. In accordance with the Children’s Online Privacy Protection Act (”COPPA”), we will not knowingly collect any personally identifiable information from children under the age of thirteen (13) without first obtaining parental consent. Prior to providing any personally identifiable information (your name, email address, address, phone number etc.), children under the age of thirteen (13) must have a parent or legal guardian complete and return (by email or regular mail) a Parental Consent Form to
Flourish Wellness, PLLC 178 Mine Lake Court, STE 200 Raleigh, NC 27615
The consent form states that the child’s “Parent” or “Legal Guardian”, by his or her signature, consents to the collection and transfer of the child’s personally identifiable information. Consent may be revoked by completing a “Revocation of Parental Consent Form” and sending it to the email or physical mailing address above. In compliance with COPPA, We are sensitive about children consulting with parents or guardians before furnishing personal information or ordering anything online.
It is also our intention to adhere to the Children’s Advertising Review Unit (CARU) Guidelines on Internet advertising with its special sensitivities regarding solicitations to children under thirteen (13). We encourage parents/guardians to supervise and join their children in exploring cyberspace.
1. TRANSFER OF DATA ABROAD
If you are visiting this Site from a country other than the country in which our servers are located, your communications with us may result in the transfer of information across international boundaries. By visiting this Site and communicating electronically with us, you consent to such transfers.
1. COMPLIANCE WITH LAWS AND LAW ENFORCEMENT
We cooperate with government and law enforcement officials and private parties to enforce and comply with the law.
We will disclose any information about you to government or law enforcement officials or private parties as we, in our sole discretion, believe necessary or appropriate to respond to claims and legal process (including without limitation subpoenas), to protect our property and rights or the property and rights of a third party, to protect the safety of the public or any person, or to prevent or stop activity we consider to be illegal or unethical. We will also share your information to the extent necessary to comply with ICANN's rules, regulations and policies.
To the extent we are legally permitted to do so, we will take reasonable steps to notify you in the event that we are required to provide your personal information to third parties as part of legal process.
1. CHANGES IN OUR PRACTICES
If we make material changes to this Policy, we will notify you here, by email, or by means of a notice on our home page, at least thirty (30) days prior to the implementation of the changes.
1. CORRECTING, UPDATING AND REMOVING PERSONAL INFORMATION
You may alter, update or deactivate your account information or opt out of receiving communications from us at any time. You may send an email to email@example.com or you may send mail to Flourish Wellness, PLLC at
Flourish Wellness, PLLC 178 Mine Lake Court, STE 200 Raleigh, NC 27615
We will respond to your request for access or to modify or deactivate your information within thirty (30) days. 9. MEDICAL PRIVACY NOTICE
This Section describes how medical information about you may be used and disclosed by us and how you can get access to this information. Please review it carefully.
1. Who Will Follow This Notice?
Health care practitioners who treat you at any of our locations, including employees, volunteers, and members of our, all departments and operating units of our organization, and all medical practices operated us, other members of our workforce, and our business associates.
1. Your Medical Information
This Section refers to your “medical information”. This means all information that identifies you and relates to your past, present or future physical or mental health or condition including information about payment and billing for the health care services you receive.
1. Our Pledge Regarding Medical Information
We understand that your medical information is personal and we are committed to its protection. We create a record of the care and services you receive to ensure that we are providing quality care and to comply with legal requirements. This notice applies to all your medical information that we maintain, whether created by our staff or others.
We are required by law to give you this notice of our legal duties and privacy practices with respect to your medical information, to follow the terms of this Privacy Notice, and to notify you following a breach of the privacy or security of your unsecured medical information.
1. How We May Use and Disclose Medical Information About You
For each category of use and disclosure, we will try to give some examples, although not every use or disclosure in the category will be listed.
1. For treatment. We may use your medical information so that we and other health care providers may provide you with medical treatment or services. Different health professionals may also share your medical information in order to coordinate the different services you need. We may disclose your medical information to people outside our offices and/or locations who may be involved in your medical care after you leave our care.
2. For Payment. We may disclose your medical information so that treatment and services you receive may be billed by us to a third party. For example, your health plan may need to know about treatment you received so they will pay us for the services provided. We may also disclose your medical insurance information to obtain prior approval from your health plan.
iii. For Healthcare Operations Purposes. We may use and disclose your medical information for our internal operations, such as business management, and administrative activities, legal and auditing functions, and insurance-related activities. We may use medical information to make sure that all of our patients receive quality care, such as reviewing our processes or to evaluate the performance of those caring for you. We may also disclose information to doctors, nurses, technicians, and other personnel for review and learning purposes. We may remove information that identifies you from this set of information so others may use it to study healthcare and healthcare delivery without learning a specific patient’s identity. Under certain circumstances, we may disclose your medical information for the health care operations of other health care providers.
1. Health Information Exchange. We may participate in Regional Health Information Organization (“RHIO”) which arranges for the electronic exchange of health information among health care providers in the state where we are located. We may exchange your health information electronically through RHIO for the purposes described in this Notice. You have the right to request that your information not be included in this exchange.
2. Individuals Involved In Your Care or Payment of Your Care. We may release your medical information to a friend or family member who is involved in your medical care, or to someone who helped pay for your care.
3. Notification. We may release your medical information to notify a family member, personal representative or another person responsible for your care of your location, general condition, or death. We also may release your medical information for certain disaster relief purposes.
vii. Contacts. We may contact you to provide appointment reminders, information about treatment alternatives, or other health related benefits and services that may be of interest to you.
viii. Worker's Compensation. We may release medical information about you for worker’s compensation or similar programs, which provide benefits for work related injuries or illnesses.
1. Mental Health Information. State laws create specific requirements for the release of mental health records. We will obtain your specific authorization to release mental medical information when required by these laws.
2. Drug & Alcohol Treatment Records. Specific rules apply to the release of certain drug and alcohol program records, and we will obtain your specific authorization to release those records as required by Federal regulation 42 CFR, Part 2.
3. Miscellaneous. We may use or disclose your medical information without your prior authorization for several other reasons. Subject to certain requirements, we may give out your medical information without prior authorization for public health purposes, abuse or neglect reporting, health oversight audits or inspections, research studies, funeral arrangements, Coroner’s investigations, organ donation, and emergencies. We also may disclose medical information when required by law in response to a request from law enforcement in specific circumstances, for specialized government functions including correctional, military or national security purposes, in response to valid judicial or administrative orders or to avoid a serious health threat. Additional specific rules may apply to mental health records.
xii. Other Disclosures. Other uses and disclosures not described above will be made only with your written authorization. For example, we require your signed authorization for uses and disclosure that constitute the sale of your medical information and for most uses and disclosures of psychotherapy notes. Additionally, we will not use or disclose your medical information for marketing purposes unless we have a signed authorization from you except that an authorization will not be required if (a) a communication occurs face-to-face; (b) consists of marketing gifts of nominal value. You may revoke your authorization at any time unless we have relied on your authorization or your authorization was required as a condition of obtaining health care services.
1. Your Rights Regarding Medical Information About You
2. Right to Inspect and Copy. In most cases you have the right to inspect or receive a copy of your medical information (or have a copy provided to an individual whom you designate) when you submit a written request. If your medical record is maintained electronically in a designated record set, you have the right to request a copy of the information in an electronic form and format. We may deny your request in certain circumstances. If you are denied access to your medical information, you may appeal.
ii.Right to Amend. If you believe the information in your record is incorrect or incomplete, you have the right to request an addendum be added to your record by submitting a written request giving your reason. We may deny your request under certain circumstances. If we deny it, we may advise you in writing of the reason or explain your rights to submit a statement of explanation.
iii. Right to an Accounting of Disclosure. You have the right to a list of those instances where we have disclosed your medical information other than for treatment, payment, healthcare operations, or where a disclosure was specifically authorized., for the Hospital’s directory, to persons involved in your care, and certain other limited situations. To request an accounting of disclosures, you must submit a written request to our Support Department.
1. Right to a Paper Copy of this Notice. If this notice was sent to you electronically you have a right to a paper copy of this notice. You may request that we send other communications of protected health information by alternative means, or to an alternative location. This request must be made in writing to the person listed below in Section 13. We are required to accommodate only reasonable requests. Please specify in your correspondence exactly how you want us to communicate with you; and if you are directing us to send it to a particular place, the contact/address information.
2. Right to Request Restrictions. You may request in writing that we not use or disclose your medical information except when specifically authorized by you, when required by law, or in an emergency. Except in the case of certain requests related to disclosures to health plans, we are not required by law to agree to your request, but we will consider the request. We will inform you of our decision.
3. Right to Request Restrictions on Disclosures to Health Plans. You may request in writing that we restrict disclosures of your medical information to a health plan for purposes of carrying out payment or healthcare operations if the disclosure is not required by law and the medical information pertains solely to a health care item or service for which you (or a person other than the health plan who is acting on your behalf) have paid us out of pocket and in full at the time of service. We must agree to a request that meets these requirements.
4. Changes to this Notice
We reserve the right to change this Section at any time. Changes will apply to medical information we already hold, as well as new information after the change occurs. We will post a copy of our current notice within our facilities and we will post it on our website at
1. Complaints and Requests
If you have questions about this notice or want to talk about a problem without filing a formal complaint, please contact Flourish Wellness, PLLC at the following number: (919) 809-5927.
If you believe your privacy has been violated, you may file a complaint with our organization or with the Secretary of the U.S. Department of Health and Human Services. Information about how to file a complaint with the Department of Health and Human Services may be found at the following website: http://www.hhs.gov/ocr/privacy/hipaa/complaints/index.html. You will not be penalized for filing a complaint.
1. GOOD FAITH ESTIMATE
**Maddie Spear, LCSW**
The following document serves as a Good Faith Estimate to share detailed information about the expected services provided by Maddie Spear at Flourish Wellness, PLLC. This information has been provided for you to provide an estimated cost of services based upon a private pay rate. The following information does not apply to individuals filing in network benefits with insurance.
**Common Service and Service Codes used at Flourish Wellness, PLLC:**
- 90791: 80 minute Initial Intake Assessment
- 90837: 50 minute Counseling/Psychotherapy
- 90847: Family Therapy with Client Present
- 99244: Comprehensive Consultation
- These are a list of common service codes and does not include all codes billed at Flourish Wellness, PLLC
**Common Diagnosis Codes used at Flourish Wellness, PLLC:**
- F43.20 Adjustment Disorder, Unspecified
- F43.23 Adjustment Disorder with mixed anxiety and depressed mood
- F41.1 Generalized Anxiety Disorder
- F43.10 Post Traumatic Stress Disorder, Unspecified
- F43.8 Other Trauma and Stressor Disorder
- F33.0 Major depressive disorder
- These are a list of common diagnostic codes and does not include all codes serviced at Flourish Wellness, PLLC
**A Note about Diagnosis:** Flourish Wellness, PLLC does not provide a diagnosis until formal evaluation has been completed. Assessment may span multiple sessions at the beginning of treatment and can be discussed further by request. Please speak to Maddie at any time about this practice if you have questions or concerns.
**Where services will be rendered:** In person or via telehealth, depending on the needs and availability of both the client and Maddie Spear, LCSW.
**Frequency of therapy:** Every client’s therapy journey is unique. The length of time you want to be in therapy and how often you need to attend sessions will be influenced by many factors including: 1) Your schedule and life circumstances 2) Therapist availability 3) Ongoing life challenges 4) The nature of your specific challenges and how you address them. We will continually assess the appropriate frequency of therapy and work together to determine when you feel you have met your goals and are ready to complete therapy.
**GOOD FAITH ESTIMATE:** Below is an estimate of how much a year of therapy would cost if you were to meet with your therapist for 52 sessions per year without skipping any weeks or needing additional sessions. There are times where these fees change and the fee you pay for services may be less or more than what is reflected below depending on your life circumstances. Additionally, not all clients will meet with their therapists on a weekly basis, or there may be times when a client needs additional sessions due to extreme stress or mental health crisis. The current full rates for counseling and psychotherapy services with Maddie Spear, LCSW are: 80-minute Intake Session at a rate of $155 and 50-minute Counseling/Psychotherapy Session at a rate of $130/session. $155 intake + ($130 session x 51) sessions per year = $6785 per year. This is the rate of services for a private pay out of pocket fee. Rates are subject to change based on insurance coverage changes or when outside services are involved. Additional fees may be incurred if additional services are needed at a rate of $75 per 20-40 minutes per week. This can include fees for additional time for crisis management, case consultation with other providers, or psychoeducation for outside supports, etc.. For example, if after a 50 minute session there are three 12 minute calls, client will be charged the initial $130 for the original session, and then an additional $75 for the 36 minutes of additional time spent with client over the course of one week. By engaging in therapeutic services, you understand the rates estimated for your projected therapy treatment. For additional information on payments, fee schedules, and methods of payment, please refer to the “Practice Policies” document sent to you upon intake.
**Disclaimer:** This Good Faith Estimate shows the costs of items and services that are reasonably expected for your health care needs for an item or service. The estimate is based on information known at the time the estimate was created. The Good Faith Estimate does not include any unknown or unexpected costs that may arise during treatment. You could be charged more if complications or special circumstances occur. The Good Faith Estimate is not a contract and therefore does not require you to obtain the items or services provided by Maddie Spear, LCSW. This Good Faith Estimate is not intended to serve as a recommendation for treatment or a prediction that you may need to attend a specified number of psychotherapy visits. The number of visits that are appropriate in your case, and the estimated cost for those services, depends on your needs and what you agree to in consultation with your therapist. You are entitled to disagree with any recommendations made to you concerning your treatment and you may discontinue treatment at any time. At the foundation of a good therapeutic relationship between client and therapist is the client’s right to autonomy and self-determination. Therefore, you (as the client) have the right to terminate services at any time. You additionally have a right to initiate a dispute resolution process if the actual amount charged to you substantially exceeds the estimated charges stated in your Good Faith Estimate ($400 or more beyond the estimated charges). You may contact the health care provider to let them know the billed charges are higher than the Good Faith Estimate. You can ask them to update the bill to match the Good Faith Estimate, ask to negotiate the bill, or ask if there is financial assistance available. You may also start a dispute resolution process with the US Department of Health and Human Services. If you choose to use the dispute resolution process, you must start the dispute process within 120 calendar days (about 4 months) of the date on 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, you will have to pay the higher amount. To learn more or access a form to start the process, go to cms.gov/nosurprises or call 1-800-985-3059.
1. CONTACT INFORMATION
Flourish Wellness, PLLC 178 Mine Lake Court, STE 200 Raleigh, North Carolina 27615, (919) 809 - 5927 firstname.lastname@example.org