Your Rights &
Our Commitment

You have the right to receive a “Good Faith Estimate” explaining how much your health care will cost. Under the law, health care providers need to give patients who don’t have certain types of health care coverage or who are not using certain types of health care coverage an estimate of their bill for health care items and services before those items or services are provided.

​

You have the right to receive a Good Faith Estimate for the total expected cost of any health care items or services upon request or when scheduling such items or services.

 

If you schedule a health care item or service at least 3 business days in advance, make sure your health care provider or facility gives you a Good Faith Estimate in writing within 1 business day after scheduling. If you schedule a health care item or service at least 10 business days in advance, make sure your health care provider or facility gives you a Good Faith Estimate in writing within 3 business days after scheduling. You can also ask any health care provider or facility for a Good Faith Estimate before you schedule an item or service. If you do, make sure the health care provider or facility gives you a Good Faith Estimate in writing within 3 business days after you ask.

 

If you receive a bill that is at least $400 more for any provider or facility than your Good Faith Estimate from that provider or facility, you can dispute the bill.

 

Make sure to save a copy or picture of your Good Faith Estimate and the bill.

For questions or more information about your right to a Good Faith Estimate, visit
www.cms.gov/nosurprises/consumers, email FederalPPDRQuestions@cms.hhs.gov, or call 1-800-985-3059.

 

PRIVACY ACT STATEMENT: CMS is authorized to collect the information on this form and any supporting documentation under section 2799B-7 of the Public Health Service Act, as added by section 112 of the No Surprises Act, title I of Division BB of the Consolidated Appropriations Act, 2021 (Pub. L. 116-260). We need the information on the form to process your request to initiate a payment dispute, verify the eligibility of your dispute for the PPDR process, and to determine whether any conflict of interest exists with the independent dispute resolution entity selected to decide your dispute. The information may also be used to: (1) support a decision on
your dispute; (2) support the ongoing operation and oversight of the PPDR program; (3) evaluate selected IDR entity’s compliance with program rules. Providing the requested information is voluntary. But failing to provide it may delay or prevent processing of your dispute, or it could cause your dispute to be decided in favor of the provider or facility.

NOTICE OF PRIVACY PRACTICES

The Brooke Center for Counseling and Wellness, LLC

info@thebrookecenter.com

(469)412-7540

​

Our Notice of Privacy Practices provides information about how we may use and disclose protected health information about you. The notice contains the client’s rights under the law. The full Notice of Privacy Practices is provided within the intake paperwork for new clients, and can be requested at any time by The Brooke Center for Counseling and Wellness, LLC. 

​

The Brooke Center for Counseling and Wellness, LLC may use or disclose your health information for the following purposes: treatment, payment, scheduling, operations, safety, law, marketing, public, health, check-in, health oversight, legal proceedings, breach notification, psychotherapy notes, and/or research. 

​

Except as described in the Notice of Privacy Practices, this practice will, consistent with its legal obligations, not use or disclose health information which identifies you without your written authorization. If you do authorize this practice to use or disclose your health information for another purpose, you may revoke your authorization in writing at any time.

​

You have the right to your health information. This includes the right to: request special privacy protections, request confidential communications, inspect and copy, amend or supplement, accounting of disclosures, paper or electronic copy of notice.

​

We reserve the right to amend this Notice of Privacy Practices at any time in the future. Until such amendment is made, we are required by law to comply with the terms of this Notice currently in effect. After an amendment is made, the revised Notice of Privacy Protections will apply to all protected health information that we maintain, regardless of when it was created or received. A copy will be provided within the client’s informed consent and we will post the current notice on our website.

​

Complaints about this Notice of Privacy Practices or how this practice handles your health information should be directed to our Privacy Officer listed at the top of this Notice of Privacy Practices.

If you are not satisfied with the manner in which this office handles a complaint, you may submit a formal complaint to:

DSHS Consumer Services and Rights Protection/Ombudsman Office by mail at Mail Code 2019, P.O. Box 149347 Austin, TX 78714-9347; or by telephone at (512) 206-5760 or (800) 252-8154 (toll free); and Office for Civil Rights, Region VI, U.S. Department of Health and Human Services, by mail at 1301 Young St., Suite 1169, Dallas, Texas 75202; or by telephone at (800) 368-1019, (214) 767-0432 (fax), or (800) 537-7697 (TDD).

 

OCRMail@hhs.gov

 

The complaint form may be found at www.hhs.gov/ocr/privacy/hipaa/complaints/hipcomplaint.pdf.
You will not be penalized in any way for filing a complaint.

We are required to retain your records for 7 years, or 5 years after a former child client has turned 18. 

 

Written Requests Required

Texas law requires that all requests for mental health records be submitted in writing. Each clinician is the legal custodian of their own client records. To request your records, you will need to contact your provider directly at their specific email address, ex. firstname@thebrookecenter.com or at info@thebrookecenter.com.

 

What to Include in Your Request

We require the following as part of the records request process:

 

• A written request (email or mail) clearly identifying the specific records you are requesting

• The name, address, phone number, and/or email address of the person or entity receiving the records

 

If records are being requested for litigation or legal purposes, please include:

 

• Case title, Cause number, and Court where the matter is pending

 

If you require a Business Records Affidavit, please indicate this in your written request.

 

• A small administrative fee may be applied for this request

• Affidavits will not be issued until payment is received

 

 

Fees for Records
Administrative fees may be charged for the preparation and release of records or for affidavit requests, as permitted by law.

 

• Credit cards are accepted for all records-related fees

 

Authorization Requirements
If you are requesting couples counseling records, family therapy records OR records for any adult other than yourself, state and federal law require one of the following:

 

• A valid court order, or

• A written authorization signed by the individual whose records are being requested
   

These requirements are governed by 45 C.F.R. §164.512(e) and Texas Health & Safety Code §§611.004, 611.0045, and 611.008.

If you believe a clinician has violated their code of ethics and/or scope of their licensing regulations, please contact the licensing board.

 

Click here to access the Texas Code.

 

Texas Behavioral Health Executive Council

1801 Congress Ave., Ste. 7.300
Austin, Texas 78701
(512) 305-7700
Investigations/Complaints 24-hour, toll-free system- (800) 821-3205

 

https://bhec.texas.gov/contact-us/ 

If you believe you have been a victim fraudulent business practices in the State of Texas please contact the Attorney General's Office to file a consumer complaint.

 

Click here to learn more about your consumer rights.

 

https://consumerprotection.texasattorneygeneral.gov/consumercomplaintportal/s/