Privacy Practices Notice

This notice describes how mental health information about you may be used and disclosed and how you can gain access to that information. Please review this notice carefully. If you are the parent/caregiver of a child that is a patient of That Therapy Place, then presume that whenever this notice says "your information," it is pertaining to your child and/or your family unit.

That Therapy Place, LLC knows that your mental health information is personal. We will not disclose your information in any unlawful, improper, or unnecessary way. We keep a record of the care and services you receive as required by Illinois Law.  

This notice informs you of the ways we may use or disclose your information, as well as your rights and responsibilities pertaining to any possible future disclosure of your mental health information. The law says That Therapy Place, LLC must keep any mental health information private if it identifies you in any way. The law also states that we must provide you with this notice that informs you of how your information is kept confidential and the circumstances in which legal duties do not require that we have your consent to disclose. The law requires that we follow this policy.

 We are required to disclose your personal information if it could prevent serious threat to the health & safety of yourself, someone else, or the public. We would only disclose this information to people who could help aid in this type of crisis situation (emergency personnel, your family members, etc.). We will, if at all possible, attempt to obtain your consent before disclosing this information. However, if you are a danger to yourself or another person, we are not required to obtain your consent.  If we are made aware of child abuse and/or elder abuse, or the abuse of a developmentally disabled person, we are required to notify the proper authorities. We are not required to obtain consent.  

Your Rights

You have the right to give us permission to disclose your mental health information by completing a Release of Information form. If at any time, you decide to revoke this ROI, you may request that we rescind your permission either in writing or verbally to us. We will then ask you to initial & date the amendment to the ROI stating that you no longer give permission for us to disclose information to whomever the ROI was addressed to, and/or we will document this in the EMR (Electronic Medical Record). 

You have the right to inspect and review your record. You also have the right to request copies; however, a reasonable charge will be added to your account. In rare circumstances, your request to review your record may be denied. We will discuss this with you during our therapy sessions.  

You have the right to request a change or amendment to any information you find in your record. To do so, you must write a letter stating the reason you feel your record contains incorrect information and also specifically outlining the change you request. In rare circumstances, your request to amend your record may be denied.  We will discuss this with you during our therapy sessions. 

You have the right to inform me of your preferred method of communication. If you prefer to only communicate in person, you must attempt to make all scheduled appointments or risk being closed from our services. If you prefer using the phone, you have a right to inform me of any phone numbers you wish to be contacted at (for instance, if you do not want to be contacted at work, etc.) You also have the right to utilize texting/email as a way to communicate with me (see Technological Communication Contract form). You are required to notify us of any change in address/phone number/insurance information. 

You have the right to request a paper copy of this notice at any time. 

If you think your right to privacy has been violated, you have the right to register a complaint with the Secretary of the Department of Health and Human Services. If you feel that your treatment was delivered in an unethical way, you also have a right to register a complaint with the Office of Ethics and Professional Review. Details about this process can be found at:  https://www.socialworkers.org/nasw/ethics/rpr.asp.

You have the right to be an active participant in your treatment. Please voice your thoughts, ideas, opinions, & complaints directly to That Therapy Place, LLC. We hope to create an open & comfortable atmosphere where we can have this kind of dialogue without any fear of consequence. If you are unhappy with our services at any time, you have the right to terminate your case.  Please notify That Therapy Place, LLC when this decision has been made. 

No Suprises Act

 GOOD FAITH ESTIMATE

That Therapy Place, LLC 

300 E. War Memorial Dr. 

Suite 201A

Peoria, IL 61614

309.431.2012

NPI:  1275123861

You are entitled to receive this Good Faith Estimate of what the charges could be for mental health therapy services provided to you by That Therapy Place, LLC. While it is not possible for That Therapy Place, LLC to know, in advance, how many psychotherapy sessions may be necessary or appropriate for a given person, this form provides an estimate of the cost of services provided. Your total cost of services will depend upon the number of sessions you attend, your individual circumstances, and the type and amount of services that are provided to you.

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. This estimate is not a contract and does not obligate you to obtain any services from That Therapy Place, LLC nor does it include any services rendered to you that are not identified here. 

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. There may be additional items or services that may be recommend as part of your care that must be scheduled or requested separately and are not reflected in this Good Faith Estimate. You could be charged more if complications or special circumstances occur. If this happens, federal law allows you to dispute the bill. 

You have the 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 (which means $400 or more beyond the estimated charges). You may contact the health care provider or facility listed 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 U.S. Department of Health and Human Services (HHS). 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 or facility, you will have to pay the higher amount. For questions or more information about your right to a Good Faith Estimate or the dispute resolution process, visit https://www.cms.gov/nosurprises/consumers or call 1- 800-985-3059. The initiation of the patient-provider dispute resolution process will not adversely affect the quality of the services furnished to you. 

That Therapy Place, LLC anticipates your treatment will require weekly 50-minute psychotherapy sessions throughout the next 12 months at $180 per session for a total of 52 weeks taking into consideration availability (reduce as appropriate for things like vacations, holidays, emergencies, sick time) for an estimated total of $180 x52 weeks. 

Based upon a fee of $180 per visit, if you attend one (psychotherapy) session per week, your estimated charge would be $720 for four visits provided over the course of one month; $1440 for eight visits over two months; or $2160 for 12 visits over three months. If you attend (psychotherapy)for a longer period, your total estimated charges will increase according to the number of session and length of treatment. If you choose to use your insurance benefits, it may reimburse some of the cost, it is your responsibility to understand your benefits, including co-pays, deductibles and out of pocket charges. We may bill your insurance directly for sessions if you agree to services and if That Therapy Place, LLC has a current contract with your insurance company. 

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. 

You are encouraged to speak with your provider at any time about any questions you may have regarding your treatment plan, or the information provided to you in this Good Faith Estimate.

Initial Assessment - $300 

Individual/Family 50-55 Minute Session - $180 

Court Session per hour (including travel) - $350 

Report or Letter Writing per hour (not court) - $150 

Cost of Records per Page - $1