STANDARD NOTICE
“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 https://www.cms.gov/nosurprises or contact Kimberly Bonde, Lic.Ac., RN directly at 404-378-1543 or via email at kbonde@intownacupuncture.com

YOUR RIGHTS AND PROTECTIONS AGAINST SURPRISE MEDICAL BILLS
(OMB Control Number: 0938-1401)

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 discuss the situation with Kimberly Bonde, Lic.Ac., RN directly, or you may contact the Georgia Office of Insurance and Fire Safety Commissioner, 404-656-2070, located at 2 M.L.K. Jr Dr SE #716, Atlanta, GA 30334

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.

NOTE: Kimberly Bonde, Lic.Ac., RN is not in-network with any insurance plans. All treatment will be provided and billed to you as a private pay patient. If you have out-of-network insurance coverage for acupuncture services you may elect to submit a “superbill” receipt, which Kimberly will provide, so that your insurance company can consider reimbursement.

HIPAA Notice of Privacy Practices

This notice describes how health information about you may be used and disclosed, and how you can get access to your health information. Notices are posted near the front desk and copies are given to all individuals receiving care. Please review this information carefully.

Understanding your health record: A record is made each time you visit Kimberly Bonde Acupuncture, Inc. Your symptoms, the practitioner’s judgments, and a plan of treatment are recorded. This record serves as a basis for planning your care and treatment at future visits, and serves as a means of communication among other health professionals who may contribute to your care. Understanding what information is retained in your record and how that information may be used will assist you to ensure it is accurate and make informed decisions about who, what, when, where, and why others may be allowed access to your health information.

Understanding your health information rights: Your health record is the physical property of Kimberly Bonde, Lic.Ac., RN, but the content is about you, and therefore belongs to you. You have the right to review or obtain a paper or electronic copy of your health record, and to request that appropriate amendments be made to your health record. You have the right to request restrictions on certain uses and disclosures of your information, to authorize disclosure of the record to others, and be given an account of those disclosures. Other than activity that has already occurred, you may revoke any further authorizations to use or disclose your health information. Should she need to contact you, you have the right to request communication by alternate means or to alternate locations.

Our responsibilities: Kimberly Bonde, Lic.Ac., RN is required to maintain the privacy of your health information and to provide you with this notice of our privacy practices. She is required to follow the terms of this notice and to notify you if she is unable to grant your request to disclose or restrict disclosure of your health information to others. Kimberly Bonde, Lic.Ac., RN reserves the right to change her practices and promises to make a good faith effort to notify you of any changes. Other than for the reasons described in this notice, Kimberly Bonde, Lic. Ac., RN agrees not to use or disclose your health information without your authorization.

Practices Regarding Disclosure of Client Health Information:
Your health information will be routinely used for treatment, payment, and quality-monitoring, and your consent, or the opportunity to agree or object, is not required in these instances:

• Treatment – Information obtained by Kimberly Bonde, Lic.Ac., RN will be entered in your record and used to plan the course of treatment. Your complete record may be shared with other licensed acupuncturists in practice at 340 Mead Road, Decatur, GA who are directly involved in your care or providing consultation about your treatment. Your practitioner’s own expectations and those of others involved in your care may also be recorded.
• Payment – Your record will be used to receive payment for services rendered by Kimberly Bonde, Lic.Ac., RN at Kimberly Bonde Acupuncture, Inc. A bill may be sent to either you or a third-party payer with accompanying documentation that identifies you, your diagnosis and/or practitioner’s impressions, and procedures performed.
• Quality Monitoring – The staff in this office will use your health information to assess the care you received and compare your treatment outcome to others. Your information may be reviewed for risk management or quality improvement purposes in our efforts to continually improve the quality and effectiveness of the care and services we provide.

In addition, the following disclosures are required by law and do not require your consent:

• Food and Drug Administration (FDA) – This office is required by law to disclose health information to the FDA related to any adverse effects of food, supplements, products, and product defects for surveillance to enable product recalls, repairs, or replacements.
• Worker’s Compensation – This office will release information to the extent authorized by law in matters of worker’s compensation.
• Public Health – This office is required by law to disclose health information to public health and/or legal authorities charged with tracking reports of birth and morbidity. This office is further required by law to report communicable disease, injury, or disability.
• Law Enforcement – (1) Your health information will be disclosed in response to a valid subpoena for law enforcement purposes, as required under state or federal law. (2) In the event that a staff member or business associate of this office believes in good faith that one or more patients, workers, or the general public are endangered due to suspected unlawful conduct of a practitioner or violations of professional or clinical standards, provisions of federal law permit the disclosure of your health information to appropriate health oversight agencies, public health authorities, or attorneys.

Kimberly Bonde, Lic.Ac., RN at Kimberly Bonde Acupuncture, Inc. considers the following as routine uses and disclosures for which specific authorization will not be requested. You have the right to request restrictions on these uses. Otherwise, Kimberly Bonde, Lic.Ac., RN will request your authorization whenever disclosure of personal health information is necessary to parties other than those referenced here.

• Business Associates – Some or all of your health information may be subject to disclosure through contracts for services to assist this office in providing health care. To protect your health information, we require these Business Associates to follow the same standards held by this office through terms detailed in a written agreement.
• Communications with Family – Using best judgment, a family member, close personal friend identified by you, personal representative, or other persons responsible for your care may be notified or given information about your care to assist them in enhancing your well-being or to confirm your whereabouts.

To receive additional information or report a problem, you may contact Kimberly Bonde, Lic.Ac., RN. If you believe your privacy rights have been violated, you have the right to file a complaint with us and/or with the U.S. Secretary of Health and Human Services with no fear of retaliation by this office.