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Good Faith Estimates

Your Right to Receive a Transparent Good Faith Estimate of Expected Costs

Effective date: January 1, 2022

 At Alliance Counseling Associates, we believe in transparency and your right to be informed about the cost of your care. In compliance with the No Surprises Act, we are committed to providing our clients with a Good Faith Estimate of the expected charges for mental health services.

What is a Good Faith Estimate?

Under the No Surprises Act, health care providers need to give patients who do not have insurance or who are not using insurance an estimate of the expected charges for medical services, including mental health care.

Who is eligible to receive a Good Faith Estimate?

All self-pay clients and those who choose not to use their insurance have the right to receive a Good Faith Estimate of expected charges.

What will the Good Faith Estimate include?

The Good Faith Estimate will include the costs associated with your mental health care services that are reasonably expected for your treatment. This may include:

  • Initial assessment and evaluation
  • Individual counseling sessions
  • Group therapy sessions
  • Any additional services that may be recommended as part of your care

What should you do if your actual bill is more than $400 greater than your Good Faith Estimate?

If the billed charges are substantially higher than the Good Faith Estimate you received, you have the right to dispute the bill. You may contact our office to discuss discrepancies, and we can assist you with the dispute process.

For more information about your rights under the No Surprises Act and the dispute process, please visit or contact our office directly.

Our Commitment to You

At Alliance Counseling Associates, we are dedicated to supporting your mental health journey. Providing a Good Faith Estimate is part of our commitment to ensuring you feel prepared and informed about the investment in your mental health care.

If you have any questions or concerns regarding the Good Faith Estimate, please do not hesitate to reach out to us.

Contact Us

  • By email: [email protected]
  • By phone number: 270-904-6567
  • By mail: 104 Reynolds Road | Glasgow, KY 42141



IF YOU HAVE ANY QUESTIONS ABOUT THIS NOTICE OR IF YOU NEED MORE INFORMATION, PLEASE CONTACT Alliance Counseling Associate’s Privacy Officer: Andrew Purcell at 104 Reynolds Road, Glasgow, KY, 42141. Phone: 270-904-6567

About This Notice
Alliance Counseling Associates (ACA) is required by law to maintain the privacy of Protected Health Information (PHI) and to give you this Notice explaining privacy practices with regard to that information. You have certain rights – and ACA has certain legal obligations – regarding the privacy of your PHI.

What is PHI?
“PHI” is information that individually identifies you and that ACA creates or gets from you or from another health care provider, health plan, your employer, or a health care clearinghouse and that relates to (1) your past, present, or future physical or mental health, (2) the provision of health care to you, or (3) the past, present, or future payment for your health care.

How ACA May Use and Disclose Your PHI
We may use and disclose your PHI in the following circumstances:
For Treatment. ACA may use or disclose your PHI to give you medical treatment or services and to manage and coordinate your medical care.
For Payment. ACA may use and disclose your PHI so that it can bill for the treatment and services you receive and so that ACA can collect payment from you, a health plan, or a third party. This use and disclosure may include certain activities that your health insurance plan may undertake before it approves or pays for the health care services ACA recommends for you, such as making a determination of eligibility or coverage for insurance benefits, reviewing services provided to you for medical necessity, and undertaking utilization review activities. For example, ACA may need to give your health plan information about your treatment in order for your health plan to agree to pay for that treatment.
For Health Care Operations. ACA may use and disclose PHI for health care operations. For example, ACA may use your PHI to contact you to remind you that you have an appointment, or to contact you to tell you about possible treatment options or alternatives.
Minors. ACA may disclose the PHI of minor children to their parents or guardians unless such disclosure is otherwise prohibited by law.
As Required by Law. ACA will disclose PHI about you when required to do so by federal, state, or local law.
To Avert a Serious Threat to Health or Safety. ACA may use and disclose PHI when necessary to prevent a serious threat to your health or safety or to the health or safety of others. But ACA will only disclose the information to someone who may be able to help prevent the threat.
Business Associates. ACA may disclose PHI to business associates who perform functions on my behalf or provide me with services if the PHI is necessary for those functions or services. For example, ACA may use another company to do billing. All ACA business associates are obligated, under contract with ACA, to protect the privacy and ensure the security of your PHI.
Military and Veterans. If you are a member of the armed forces, ACA may disclose PHI as required by military command authorities.
Workers’ Compensation. ACA may use or disclose PHI for workers’ compensation or similar programs that provide benefits for work-related injuries or illness.
Public Health Risks. ACA may disclose PHI for public health activities. This includes disclosures to: (1) prevent or control disease, injury or disability; (2) report child abuse or neglect, and (3) a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition.
Abuse, Neglect, or Domestic Violence. ACA may disclose PHI to the appropriate government authority if ACA believes a client has been the victim of abuse, neglect, or domestic violence and the patient agrees or ACA is required or authorized by law to make that disclosure.
Health Oversight Activities. ACA may disclose PHI to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and similar activities that are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.
Data Breach Notification Purposes. ACA may use or disclose your PHI to provide legally required notices of unauthorized access to or disclosure of your PHI.
Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, ACA may disclose PHI in response to a court or administrative order. ACA also may disclose PHI in response to a subpoena, discovery request, or other legal process from someone else involved in the dispute, but only if efforts have been made to tell you about the request or to get an order protecting the information requested. ACA may also use or disclose your PHI to defend itself in the event of a lawsuit.
Law Enforcement. ACA may disclose PHI, so long as applicable legal requirements are met, for law enforcement purposes.
Military Activity and National Security. If you are involved with military, national security or intelligence activities or if you are in law enforcement custody, ACA may disclose your PHI to authorized officials so they may carry out their legal duties under the law.

Uses and Disclosures That Require Me to Give You an Opportunity to Object and Opt Out

Individuals Involved in Your Care or Payment for Your Care
. Unless you object, ACA may disclose to a member of your family, a relative, a close friend or any other person you identify, your PHI that directly relates to that person’s involvement in your health care. If you are unable to agree or object to such a disclosure, ACA may disclose such information as necessary if ACA determines that it is in your best interest.
Disaster Relief. ACA may disclose your PHI to disaster relief organizations that seek your PHI to coordinate your care, or notify family and friends of your location or condition in a disaster. ACA will provide you with an opportunity to agree or object to such a disclosure whenever ACA practicably can do so.

Your Written Authorization is Required for Other Uses and Disclosures
The following uses and disclosures of your PHI will be made only with your written authorization:
1. Most uses and disclosures of psychotherapy notes;
2. Uses and disclosures of PHI for marketing purposes;
Other uses and disclosures of PHI not covered by this Notice or the laws that apply to ACA will be made only with your written authorization. If you do give ACA authorization, you may revoke it at any time by submitting a written revocation to ACA and ACA will no longer disclose the PHI under the authorization.

Your Rights Regarding Your PHI
You have the following rights, subject to certain limitations, regarding your PHI:
Right to Inspect and Copy. You have the right to inspect and copy PHI that may be used to make decisions about your care or payment for your care. ACA has up to 30 days to make your PHI available to you and ACA may charge you a reasonable fee for the costs of copying, mailing or other supplies associated with your request.
Right to a Summary or Explanation. ACA can also provide you with a summary of your PHI, rather than the entire record, or ACA can provide you with an explanation of the PHI which has been provided to you, so long as you agree to this alternative form and pay the associated fees.
Right to Get Notice of a Breach. You have the right to be notified upon a breach of any of your unsecured PHI.
Right to Request Amendments. If you feel that the PHI ACA has is incorrect, you may ask for it to be amended.
Right to an Accounting of Disclosures. You have the right to ask for an “accounting of disclosures,” which is a list of the disclosures ACA made of your PHI. This right applies to disclosures for purposes other than treatment, payment or healthcare operations as described in this Notice.
Right to Request Restrictions. You have the right to request a restriction or limitation on the PHI ACA uses or discloses for treatment, payment, or healthcare operations.
Out-of-Pocket-Payments. If you paid out-of-pocket in full for a specific item or service, you have the right to ask that your PHI not be disclosed to a health plan for purposes of payment or healthcare operations.
Right to Request Confidential Communications. You have the right to request that ACA communicate with you only in certain ways to preserve your privacy.
Right to a Paper Copy of This Notice. You have the right to a paper copy of this Notice, even if you have agreed to receive this Notice electronically. You may request a copy of this Notice at any time.

Changes To This Notice
ACA reserve the right to change this Notice.

You may file a complaint with ACA or with the Secretary of the United States Department of Health and Human Services if you believe your privacy rights have been violated. To file a complaint with ACA, contact the Privacy Officer at the address listed at the beginning of this Notice. All complaints must be made in writing and should be submitted within 180 days of when you knew or should have known of the suspected violation. There will be no retaliation against you for filing a complaint. To file a complaint with the Secretary, mail it to: Secretary of the U.S. Department of Health and Human Services, 200 Independence Ave, S.W., Washington, D.C. 20201. Call (202) 619-0257 (or toll free (877) 696-6775) or go to the website of the Office for Civil Rights,, for more information. 

Contact Us

  • By email: [email protected]
  • By phone number: 270-904-6567
  • By mail: 104 Reynolds Road | Glasgow, KY 42141