Good Faith Estimate

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Your Rights & What to Expect at 406 Therapeutics LLC

At 406 Therapeutics LLC, I want you to feel informed, respected, and empowered—both financially and emotionally. As part of the No Surprises Act, you have the right to receive a Good Faith Estimate that explains the expected cost of your mental health services.

GOOD FAITH ESTIMATE (GFE) - For Services Under the No Surprises Act

Under the law, health care providers are required to give clients who do not have insurance or who are not using insurance an estimate of the expected charges for medical services, including psychotherapy. You have the right to receive a Good Faith Estimate explaining how much your mental health services may cost.

Your Rights Under the Good Faith Estimate

· You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency mental health services.

· You may ask your therapist for a Good Faith Estimate before scheduling a service, or at any time during your treatment.

· If you receive a bill that is $400 or more above your Good Faith Estimate, you may dispute the bill.

· Make sure to save a copy or picture of your Good Faith Estimate.

Good Faith Estimate Disclaimer

The following is only an estimate of the cost of services. Your actual total cost may vary depending on:

the number of sessions you choose to attend,

changes in frequency of sessions,

changes in treatment needs or goals,

crisis or additional sessions requested by you.

Therapy is highly individualized, and the duration of treatment varies by client.

Dispute Resolution

If you receive a bill that is at least $400 more than this Good Faith Estimate, you may start a dispute process with the U.S. Department of Health and Human Services (HHS).

For questions or more information about your right to a Good Faith Estimate or the dispute process, visit: www.cms.gov/nosurprisesor call 1-800-985-3059.

Privacy & HIPAA Notice – Montana

Effective Date: September 1, 2025
Last Updated: January 7, 2026

Your privacy is important. This notice explains how your protected health information (PHI) may be used, your rights under HIPAA, how we protect your information online, and your acknowledgment of receipt.

1. Your Rights

As a client, you have the right to:

· Access your records: Request electronic or paper copies of your therapy records or treatment summaries.

· Request corrections: Ask for amendments if information is inaccurate or incomplete.

· Request confidential communications: Choose how and where I contact you (phone, email, or portal).

· Limit disclosures: Request restrictions on sharing PHI; I will accommodate whenever possible.

· Receive a disclosure accounting: Get a list of who your information has been shared with outside routine care, billing, or operations.

· Receive a copy of this notice: Paper or electronic.

· Designate someone to act on your behalf: Legal guardian, medical power of attorney, or court-appointed representative.

· File a complaint: With me, 406 Therapeutics LLC, or the U.S. Department of Health & Human Services (HHS) without fear of retaliation.

Contact for questions or complaints:
Ashley Atkins, LCSW – 406 Therapeutics LLC
aatkins406@gmail.com | 406-260-5257
HHS Office for Civil Rights: www.hhs.gov/ocr/privacy/hipaa/complaints

2. How Your PHI May Be Used or Disclosed

Treatment:
To provide, coordinate, or manage care. Example: Sharing information with another provider at your request.

Payment:
To bill and receive payment from insurance or other payers. Example: Submitting claims to verify coverage.

Healthcare Operations:
To manage the practice, review quality, and improve services. Example: Supervision, audits, or internal training.

Appointment Communications:
Confirming or reminding you of appointments, or scheduling changes. Your preferences will be respected.

Telehealth Sessions:
Telehealth is conducted using secure platforms to protect your PHI. Instructions will be provided for portal or platform use.

Mandatory Disclosures:
I am required to disclose PHI without your consent in situations including:

· Risk of harm to self or others

· Suspected abuse or neglect of a child, elder, or dependent adult

· Court orders or judge-signed mandates

· Public health or safety emergencies

· Law enforcement or workers’ compensation investigations

Other Disclosures:
Any use of PHI outside these situations requires your written authorization, which can be revoked at any time.

3. Special Protections for Children & Adolescents

· Privacy: Minors have the right to confidential therapy.

· Parental access: Parents or guardians generally will not receive session details unless legally required or necessary for safety.

· Montana law: Minors 16+ may consent to mental health treatment without parental permission. (MCA 53-21-112)

· Trust & transparency: When disclosure is required for safety or legal reasons, I will discuss it with the child when appropriate.

4. Business Associates

Some services may involve third-party vendors (business associates), including:

· Electronic health record systems

· Billing and practice management software

· Telehealth platforms

These associates are contractually required to protect your PHI under HIPAA.

5. Data Security & Breach Notification

I take reasonable administrative, technical, and physical measures to protect your PHI.
If there is a breach of unsecured PHI, you will be notified without unreasonable delay and within 60 days of discovery.

6. Website & Online Privacy

· PHI: Therapy notes and protected health information are never collected or stored via the website.

· Personal info: Name, email, and phone may be collected when contacting the practice voluntarily.

· Unencrypted email: Avoid sharing sensitive information via standard email; secure communication will be arranged once you become a client.

· Cookies & analytics: We may use cookies or analytics tools for website performance; these do not contain PHI.

· External links: We are not responsible for other websites’ privacy practices.

7. Record Retention

Client records are maintained according to Montana law and professional standards.

8. Updates to This Notice

This notice may be updated periodically. The most current version is always posted on the website and available upon request.

Effective Date: September 1, 2025
Last Updated: November 19, 2025

At 406 Therapeutics LLC, your privacy is extremely important to us. This Privacy Policy explains how we collect, use, and protect your information when you visit our website or communicate with us online.

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1. Information We Collect
We may collect the following types of information:
Personal Information: Information you voluntarily provide (such as your name, phone number, or email address) when you fill out a contact form, request an appointment, or communicate with us.
Non-Personal Information: Data automatically collected through cookies or analytics tools (such as your browser type, IP address, and pages visited) to help us improve our website and user experience.

We do not collect or store therapy notes, clinical records, or any protected health information (PHI) through this website.

2. How We Use Your Information
We use the information you provide to:
Respond to inquiries or appointment requests
Communicate about scheduling or services
Improve website performance and accessibility

We will never sell, rent, or share your personal information with third parties for marketing purposes.

3. Use of Email and Online Communication
Please note that messages sent through our website or regular email may not be fully secure. For your protection, avoid sharing sensitive health information through unencrypted online forms or email. Secure communication will be arranged once you become a client.

4. Cookies and Analytics
Our website may use cookies or third-party analytics tools (like Google Analytics) to understand how visitors use our site. You can disable cookies through your browser settings if you prefer not to share this information.

5. Data Security
We take reasonable administratilve and technical measures to protect your information from unauthorized access or disclosure. However, no online system is completely secure.

6. Links to Other Websites
Our website may contain links to other sites. We are not responsible for the content or privacy practices of those websites.

7. Your Rights
You have the right to:
Request access to the personal information we hold about you
Request correction or deletion of your personal data (where applicable)
Withdraw consent for us to contact you

To exercise these rights, please contact us at aatkins406@gmail.com

8. HIPAA Notice
If you become a client, your health information will be protected under the Health Insurance Portability and Accountability Act (HIPAA). You will receive a separate Notice of Privacy Practices explaining how your protected health information (PHI) is used and disclosed for clinical and administrative purposes.

9. Updates to This Policy
We may update this Privacy Policy periodically. The most current version will always be posted on our website.

10. Contact Us
If you have questions about this Privacy Policy or our privacy practices, please contact:

406 Therapeutics LLC
30 E Washington St

Ste C
Kalispell, MT 59901
aatkins406@gmail.com
406-260-5257

Please note that any messages sent through this website or its contact forms are not secure or HIPAA-compliant. While I make every effort to protect your privacy, confidentiality cannot be guaranteed through email or website messaging. For confidential or urgent matters, please contact me directly by phone or schedule an appointment through secure, HIPAA-compliant platforms.