Kelly Donovan MFT Licensed Therapist

OFFERING ONLINE SERVICES

Kelly Donovan MFT
Licensed Therapist

808-938-4162

Disclosure Notice Regarding Patient Protections Against Surprise Billing

Instructions for Providers and Facilities (For use beginning January 1, 2022) Section 2799B-3 of the Public Health Service Act (PHS Act) requires health care providers and facilities to make publicly available, post on a public website of the provider or facility (if applicable), and provide a one-page notice that includes information in clear and understandable language on: (1) the restrictions on providers and facilities regarding balance billing in certain circumstances, (2) any applicable state law protections against balance billing, and (3) information on contacting appropriate state and federal agencies in the case that an individual believes that a provider or facility has violated the restrictions against balance billing. Health care providers and facilities may, but aren’t required to, use this model notice to meet these disclosure requirements. To use this document properly, the provider or facility should review and complete it in a manner consistent with applicable state and federal law. HHS considers use of this model notice in accordance with these instructions to be good faith compliance with the disclosure requirements of section 2799B-3 of the PHS Act and 45 CFR 149.430, if all other applicable PHS Act requirements are met. If a state develops model language for its disclosure notice that is consistent with section 2799B-3 of the PHS Act, HHS will consider a provider or facility that makes good faith use of the state-developed model language to be compliant with the federal requirement to include information about state law protections. Public Disclosure Requirements The disclosure notice must be publicly available, and (if applicable) posted on a provider’s or facility’s public website. - To satisfy the public disclosure requirement, providers and facilities must prominently display a sign with the required disclosure information in a location of the provider or facility, such as, where individuals schedule care, check-in for appointments, or pay bills, unless the provider doesn’t have a publicly accessible location. - To satisfy the separate requirement to post the disclosure on a public website, the disclosure or a link to the disclosure must appear on a searchable homepage of the provider’s or facility’s public website. Who should get this notice In general, providers and facilities must give the disclosure notice to individuals who are participants, beneficiaries, or enrollees of a group health plan or group or individual health insurance coverage offered by a health insurance issuer, including covered individuals in a health benefits plan under the Federal Employees Health Benefits Program, and to whom they furnish items or services, and then only if such items or services are furnished at a health care facility, or in connection with a visit at a health care facility. Provision of the notice Providers and facilities must provide the notice in-person, by mail, or via email, as selected by the individual. The disclosure notice must be limited to one-page (double-sided) and must use a font size of 12-points or larger. Providers and facilities must issue the disclosure notice no later than the date and time on which they request payment from the individual (including requests for co-payment or coinsurance made at the time of a visit to the provider or facility). If the provider or facility doesn’t request payment from the individual, the notice must be provided no later than the date on which the provider or facility submits a claim for payment to the plan or issuer. Language access Use of Plain Language Health care providers,facilities, plans, and issuers are encouraged to use plain language in the disclosure notice and test the notice for clarity and usability when possible. Plain language, accessibility, and language access resources: - Plain language.gov/guidelines - Section508.gov - LEP.gov Compliance with Federal Civil Rights Laws Entities that receive federal financial assistance must comply with federal civil rights laws that prohibit discrimination. These laws include section 1557 of the Affordable Care Act, Title VI of the Civil Rights Act of 1964, and section 504 of the Rehabilitation Act of 1973. Section 1557 and title VI require covered entities to take reasonable steps to ensure meaningful access to individuals with limited English proficiency, which may include offering language assistance services such as translation of written content into languages other than English. Section 1557 and section 504 require covered entities to take appropriate steps to ensure effective communication with individuals with disabilities, including provision of appropriate auxiliary aids and services. Auxiliary aids and services may include interpreters, large print materials, accessible information and communication technology, open and closed captioning, and other aids or services for persons who are blind or have low vision, or who are deaf or hard of hearing. Information provided through information and communication technology also must be accessible to individuals with disabilities, unless certain exceptions apply. Providers and facilities are reminded that the disclosure notice must comply with applicable state or federal language-access standards

Privacy Commitment

KELLY DONOVAN ,respects and is committed to protecting your privacy. Generally, you can browse through our Website without giving us any information about yourself. When we do need to collect your PII (defined below) to provide you with the Service, or when you choose to provide us with your PII, this Privacy Policy describes how we collect, use and disclose your PII, except for personal health information submitted by you in the course of using our Service. Any conflict between this Privacy Policy and the HIPAA Policy with respect to such submitted personal health information shall be resolved in favor of the HIPAA Policy. Also, please note that, unless we define a term in this Privacy Policy, all capitalized terms used in this Privacy Policy have the same meanings as in our Terms of Service. Therefore, please make sure that you have read and understand our Terms of Service. Changes to this Privacy Policy Any information that is collected via our Website, App or the Service is covered by the Privacy Policy or the HIPAA Policy in effect at the time such information is collected. We may amend this Privacy Policy from time to time. If we make any substantial changes in the way we use your PII, we will notify you of those changes by posting on the Service and Website or by sending you an email or other notification, and we will update the “Updated Date” above to indicate when those changes will become effective. Information Collection Personally identifiable Information (“PII“) means any information that may be used to identify an individual, including, but not limited to, a first and last name, email address, a home, postal or other physical address, and phone number. Account Information. We collect your PII when you register with the THE PATIENT account. If you create an account through the Website, we may also collect your title, birth date, gender, occupation, industry, personal interests, and other information that is not considered PII because it cannot be used by itself to identify you. Cookies and Tracking Technology. A “cookie” is a small data file that certain websites write to your hard drive when you visit them. A cookie file can contain information such as a user ID that the website uses to track the pages you’ve visited, but the only PII a cookie can contain is information you supply yourself. A cookie can’t read data off your hard disk or read cookie files created by other websites. Some parts of the Service use cookies to understand user traffic patterns and to tell us how and when you interact with our Website and Service. We do this in order to determine the usefulness of our Website and Service information to our users, to see how effective our navigational structure is in helping users reach that information and to customize and improve our Website and Service. Unlike persistent cookies, session cookies are deleted when you log off from the Website, App and Service and close your browser. If you prefer not to receive cookies while browsing our Website and Service, you can set your browser to warn you before accepting cookies and refuse the cookie when your browser alerts you to its presence. You can also refuse all cookies by turning them off in your browser. You do not need to have cookies turned on to use/navigate through many parts of our Website and Service, although if you do so, you may not be able to access all portions or features of the Website and Service. Some third-party services providers that we engage (including third-party advertisers) may also place their own cookies on your hard drive. Note that this Privacy Policy covers only our use of cookies and does not include use of cookies by such third parties. “Web Beacons” (also known as Web bugs, pixel tags or clear GIFs) are tiny graphics with a unique identifier that may be included on our Website, App and Service for several purposes, including to deliver or communicate with cookies, to track and measure the performance of our Website and Service, to monitor how many visitors view our Website and Service, and to monitor the effectiveness of our advertising. Unlike cookies, which are stored on the 3 3041753v.1 user’s hard drive, Web Beacons are typically embedded invisibly on web pages (or in an e-mail). Information Related to Your Use of the Service. If you have not created an account, when you use our Service, you use our Service and Website anonymously. We do automatically log your IP address (the Internet address of your computer) and other information such as your browser type, operating system, the web page that you were visiting before accessing our Website and Service, the pages or features of our Website and Service to which you browsed to give us an idea of which part of our Website and Service you visit and how long you spend there (we refer to this information as “Log Data“). But we do not link your IP address to any PII unless you have logged in via your account. We use Log Data to administer the Website and Service and we analyze (and may engage third parties to analyze) Log Data to improve, customize and enhance the Website and Service by expanding their features and functionality and tailoring them to our users’ needs and preferences. Information Sent by Your Mobile Device. We collect certain information that your mobile device sends when you use our Website and Service, like a device identifier, user settings and the operating system of your device, as well as information about your use of our Website and Service. You understand that, by logging in on your mobile device, some information pertaining to your medical treatment may be stored to your mobile device. We are not responsible for any unauthorized access by any third party to such information on your mobile device. Location Information. When you use our website, we may collect and store information about your location by converting your IP address into a rough geo-location or by accessing your mobile device’s GPS coordinates or course location if you enable location services on your device. We may use location information to improve and personalize our Website for you. If you do not want us to collect location information, you may disable that feature on your mobile device. Your Choices Opt-Out. We may periodically send you free newsletters and e-mails that directly promote our Service. When you receive such promotional 4 3041753v.1 communications from us, you will have the opportunity to “opt-out” (either through your account or by following the unsubscribe instructions provided in the e-mail you receive). We do need to send you certain communications regarding the Service and you will not be able to opt out of those communications – e.g., communications regarding updates to our Terms of Service or this Privacy Policy or information about billing. Information Sharing and Disclosure Your PII is not shared outside of the Companies without your permission, except as described below. Information Shared with Our Services Providers. We may engage third-party services providers to work with us to administer and provide the Service. These third-party services providers have access to your PII only for the purpose of performing services on our behalf and are expressly obligated not to disclose or use your PII for any other purpose. Information Shared with Third Parties. Information Disclosed in Connection with Business Transactions. Information that we collect from our users, including PII, is considered to be a business asset. Thus, if we are acquired by a third party as a result of a transaction such as a merger, acquisition or asset sale or if our assets are acquired by a third party in the event we go out of business or enter bankruptcy, some or all of our assets, including your PII, may be disclosed or transferred to a third party acquirer in connection with the transaction. Information Disclosed for Our Protection and the Protection of Others. We cooperate with government and law enforcement officials or private parties to enforce and comply with the law. We may disclose any information about you to government or law enforcement officials or private parties as we, in our sole discretion, believe necessary or appropriate: (i) to enforce our Terms of Service, (ii) to respond to claims, legal process (including subpoenas); (iii) to protect our property, rights and safety and the property, rights and safety of a 5 3041753v.1 third party, our users, or the public in general; (iv) to stop any activity that we consider illegal, unethical or legally actionable activity; and (v) as required in accordance with HIPAA or related applicable local, state or federal laws (please refer to the HIPAA Policy). Your Ability to Review Your Account and Information If you are a registered user with an account, you can review your PII by going to PORTAL LINK and signing in. Data Security Your account information is password-protected for your privacy and security. The Companies safeguard the security of the information you provide to us with physical, electronic, and managerial procedures. In certain areas of our Website, we use industry-standard SSL-encryption to enhance the security of data transmissions. While we strive to protect your PII, we cannot ensure the security of the information you transmit to us, and so we urge you to take every precaution to protect your PII when you are on the Internet. Change your passwords often, use a combination of letters and numbers, and make sure you use a secure browser. Responding to Do Not Track Signals Our Website does not have the capability to respond to “Do Not Track” signals received from various web browsers. Children and Privacy Our Website and Service do not target and are not intended to attract children under the age of 13. We do not knowingly solicit PII from children under the age of 13 or send them requests for PII. If we learn that we have collected PII of a child under 13 directly from that child we will take steps to delete such information from our files as soon as possible. Notwithstanding the foregoing, 6 3041753v.1 we may collect PII about children under 13 that parents or guardians provide to us when establishing an account for their children’s records. Third Party Sites The Website and Service contain links to other sites that are owned or operated by third parties. We are not responsible for the content, privacy or security practices of any third parties. To protect your information, we encourage you to learn about the privacy policies of those third parties. International Transfer Your information is stored by the Companies on controlled servers with limited access and may be stored and processed in the United States or any other country where the Companies or agents are located. If you’re located outside the United States and choose to provide your PII to us, we may transfer your PII to the United States and process it there. Those who choose to access and use the Service from outside the U.S. do so on their own initiative, at their own risk, and are responsible for compliance with applicable laws. Questions or Suggestions If you have questions or concerns about our collection, use, or disclosure of your PII, please contact us