Right to Receive a Good Faith Estimate of Expected Charges

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 1 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 1-800-985-3059.

At Clarke Counseling LLC, your clinician will give you a written Good Faith Estimate after you schedule as a self-pay client, or any time you ask.

Notice of Privacy Practices

Clarke Counseling LLC · Effective date: October 13, 2026

Who we are

This Notice applies to psychotherapy services provided by Clarke Counseling LLC and its clinicians, Tomas Clarke, MA, LPC, LPCC and Samantha (Sammie) Day, MSW, LCSW, LICSW. We are required by law to maintain the privacy of your protected health information (“PHI”), to give you this Notice of our legal duties and privacy practices, to notify you following a breach of unsecured PHI, and to abide by the terms of the Notice currently in effect.

To the extent that we have your substance use disorder patient records, subject to 42 CFR part 2, we will not share that information for investigations or legal proceedings against you without (1) your written consent or (2) a court order and a subpoena.

How your health information may be used and disclosed

Uses and disclosures that do not require your authorization

• Treatment. To provide, coordinate, or manage your care, including coordination with another provider treating you.
• Payment. To bill and collect payment — including submitting claims to your insurer through a billing affiliate (Collective Counseling Solutions, LLC or Westside Behavioral Care Inc, depending on your clinician and plan), verifying coverage, or providing a superbill.
• Health care operations. Quality review, training, licensing, and business planning.
• Business associates. Vendors and billing affiliates that support the practice (electronic health record, telehealth, payment platforms, Collective Counseling Solutions, LLC, and Westside Behavioral Care Inc) under written agreements requiring them to protect your PHI.
• Public health and safety. To prevent or lessen a serious and imminent threat, and for public-health activities permitted by law.
• Required by law. Including mandatory reporting of suspected maltreatment of children and vulnerable or at-risk adults, duty-to-warn obligations, and disclosures to HHS to confirm compliance with federal privacy law.
• Health research; health oversight and government functions; workers’ compensation; organ/tissue and decedent purposes; law enforcement, court orders, and subpoenas; and personal representatives. As permitted or required by law, and after we confirm authority where applicable.
• Appointment reminders and services. To remind you of appointments, including by email or text sent through the practice’s electronic health record, and to tell you about treatment alternatives or other services we offer.

Disclosures you have the opportunity to object to

Family, friends, or others involved in your care. We may share PHI with a family member, friend, or other person you identify as involved in your care or in paying for it, unless you object in whole or in part. In an emergency, or if you are unable to respond, we may share limited information if we believe it is in your best interest, and we will give you the chance to object as soon as possible afterward.

Substance use disorder (Part 2) records. In all cases, if we have substance use disorder patient records about you subject to 42 CFR part 2, we cannot use or share information in those records in civil, criminal, administrative, or legislative investigations or proceedings against you without (1) your consent or (2) a court order and a subpoena. This protection applies to records that are actually subject to Part 2 — for example, records received from a federally assisted substance use disorder treatment program — not automatically to every mention of substance use in your file.

Redisclosure. After we have shared your information in a permitted way, it is possible for the recipient to share it again. Upon such redisclosure, the information may no longer be protected by the HIPAA Privacy Rule.

Uses and disclosures that require your written authorization

Most uses and disclosures of psychotherapy notes, marketing, sale of PHI, and any purpose not described above require your written authorization, which you may revoke at any time in writing (except to the extent we have already relied on it).

State law

Where Colorado or Minnesota law provides greater privacy protection than HIPAA, we follow state law. For example, the Minnesota Health Records Act generally requires your signed consent before we release your health records, including for some purposes HIPAA would otherwise allow.

Your rights regarding your health information

• Right to inspect and copy — including an electronic copy. This covers your record other than psychotherapy notes. We will respond within 30 days of your written request; a reasonable, cost-based fee may apply.
• Right to amend. You may request in writing that we amend information you believe is incorrect or incomplete. If we deny your request, we will explain why in writing within 60 days.
• Right to request restrictions. You may ask us to limit how we use or share your PHI for treatment, payment, or health care operations. We are not required to agree, with one exception: if you pay for a service out of pocket and in full, you may ask us not to share information about that service with your health plan, and we will agree unless the law requires the disclosure.
• Right to confidential communications. You may ask us to contact you in a specific way or at a specific address or phone number. We will agree to all reasonable requests.
• Right to an accounting of disclosures. You may request a list of disclosures we have made for purposes other than treatment, payment, health care operations, or those you authorized, covering up to six years. We will respond within 60 days. The first list in a 12-month period is free; a reasonable, cost-based fee may apply to additional requests.
• Right to choose someone to act for you. A person with legal authority can exercise your rights; we will verify that authority first.
• Right to a paper copy of this Notice, and to breach notification.

Changes to this Notice

We reserve the right to change the terms of this Notice, and changes will apply to all PHI we maintain. The current Notice will be posted on this page, available in the client portal, and provided to you on request.

Your Rights as a Client

• You are entitled to information about your clinician’s methods of therapy, the techniques used, the expected duration of therapy (if known), and the fee structure.
• You may seek a second opinion from another therapist, and you may end therapy at any time.
• In a professional relationship, sexual intimacy between a therapist and a client is never appropriate. If it occurs, it should be reported to the licensing board.
• You may revoke your consent to treatment, or any release of information you have signed, in writing at any time.
• What you share in therapy is confidential, with the limited legal exceptions explained in your intake paperwork and in the Notice above.

Each client receives a full disclosure statement and informed consent, specific to their state and clinician, before or at the start of care.

Questions & Complaints

If you believe your privacy rights have been violated, you may file a complaint with our Privacy Officer or with the U.S. Department of Health and Human Services, Office for Civil Rights, 200 Independence Ave. S.W., Washington, D.C. 20201, 1-877-696-6775. You will not be penalized or retaliated against for filing a complaint.

Concerns about a clinician’s professional conduct may also be directed to the licensing board in the state where you receive services:

• Colorado: Department of Regulatory Agencies (DORA), Division of Professions and Occupations — State Board of Social Work Examiners or State Board of Licensed Professional Counselor Examiners, 1560 Broadway, Suite 1350, Denver, CO 80202 · (303) 894-7800
• Minnesota: Minnesota Board of Social Work (social workers) or Minnesota Board of Behavioral Health and Therapy (professional counselors), St. Paul, MN