Good Faith Estimate
Your right to a Good Faith Estimate
Under the No Surprises Act, you have the right to receive a Good Faith Estimate (GFE) of expected charges before receiving any scheduled health care service. This applies to clients who are uninsured or who choose not to use their insurance.
A Good Faith Estimate will be provided to you before your first appointment. It will itemize the expected costs of the services discussed, including session fees and anticipated number of sessions or evaluation components.
The Good Faith Estimate is not a contract and does not require you to obtain the services listed. Actual charges may differ if circumstances change. If you receive a bill that is at least $400 more than your Good Faith Estimate, you have the right to dispute the charge.
For questions about your Good Faith Estimate or to request one prior to scheduling, contact: kevin@mckenziepsychology.com or 520.230.2530. For more information about your rights under the No Surprises Act, visit cms.gov/nosurprises.
Notice of Privacy Practices
Notice of Privacy Practices
THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
McKenzie Psychology LLC
Kevin McKenzie, Psy.D. · Licensed Psychologist · Arizona
1661 N. Swan Rd., Ste. 240, Tucson, AZ 85712 · 520-230-2530 · kevin@mckenziepsychology.com
I. My Pledge Regarding Your Health Information
I understand that health information about you and your health care is personal. I am committed to protecting health information about you. I create a record of the care and services you receive from me. I need this record to provide you with quality care and to comply with certain legal requirements. This Notice applies to all records of your care generated by this practice.
I am required by law to:
- ·Maintain the privacy and security of your protected health information (PHI).
- ·Provide you with this Notice of my legal duties and privacy practices with respect to health information about you.
- ·Follow the terms of the Notice currently in effect.
- ·Notify you promptly if a breach occurs that may have compromised the privacy or security of your information.
I may change the terms of this Notice. If I do, the updated Notice will be available upon request and will apply to all health information I maintain about you.
II. How I May Use and Disclose Health Information About You
The following categories describe the ways I use and disclose health information. Not every use or disclosure in a category will be listed, but all permitted uses and disclosures fall within one of these categories.
- ·Treatment, Payment, or Health Care Operations. Federal privacy rules allow health care providers who have a direct treatment relationship with a patient to use or disclose PHI without written authorization to carry out treatment, payment, or health care operations. For example, if I consult with another licensed health care provider about your condition, I am permitted to use and disclose your PHI to assist in your diagnosis and treatment. Treatment includes coordination and management of care with third parties, consultations between providers, and referrals. McKenzie Psychology LLC is a private-pay practice. PHI used for payment purposes is limited to generating invoices, superbills, and related billing records.
- ·Appointment Reminders and Health-Related Communications. I may use and disclose your PHI to contact you with appointment reminders, information about treatment alternatives, or other health-related services I offer.
- ·As Required by Law. I will disclose your PHI when required to do so by applicable federal, state, or local law.
- ·Public Health and Safety. I may disclose your PHI for public health activities, including reporting to public health authorities as required by law, reporting suspected abuse or neglect of a child, elder, or dependent adult, and preventing or reducing a serious and imminent threat to the health or safety of a person or the public.
- ·Health Oversight Activities. I may disclose your PHI to a health oversight agency for activities authorized by law, including audits, investigations, and inspections necessary for oversight of the health care system and government benefit programs.
- ·Lawsuits and Disputes. If you are involved in a lawsuit or dispute, I may disclose health information in response to a court or administrative order, subpoena, discovery request, or other lawful process, but only after making efforts to notify you or obtain a protective order.
- ·Law Enforcement. I may disclose your PHI for law enforcement purposes as required by law, including reporting crimes occurring on my premises.
- ·Coroners and Medical Examiners. I may disclose your PHI to a coroner or medical examiner performing duties authorized by law.
- ·Research. Under certain circumstances and with appropriate protections in place, I may use or disclose your PHI for research purposes.
- ·Specialized Government Functions. I may disclose your PHI for specialized government functions, including ensuring the proper execution of military missions, protecting the President of the United States, conducting intelligence or counterintelligence operations, and ensuring the safety of those in correctional institutions.
- ·Workers' Compensation. I may disclose your PHI as authorized by and as necessary to comply with workers' compensation laws and similar programs. My preference is to obtain your authorization before doing so when possible.
- ·Disclosures to Family, Friends, or Others Involved in Your Care. I may provide your PHI to a family member, friend, or other person involved in your care or the payment for your care, unless you object. You have the right to object in whole or in part. In emergency situations, an opportunity to object may be obtained retroactively.
III. Certain Uses and Disclosures Require Your Written Authorization
- ·Psychotherapy Notes. I keep psychotherapy notes as defined in 45 CFR § 164.501. Any use or disclosure of such notes requires your written authorization unless the use or disclosure is: for my use in treating you; for my use in training or supervising mental health practitioners to help them improve their skills; for my use in defending myself in legal proceedings instituted by you; for use by the Secretary of Health and Human Services to investigate my compliance with HIPAA; required by law and limited to the requirements of such law; required by law for certain health oversight activities pertaining to the originator of the psychotherapy notes; required by a coroner performing duties authorized by law; or required to help avert a serious threat to the health and safety of others.
- ·Marketing. I will not use or disclose your PHI for marketing purposes without your written authorization.
- ·Sale of PHI. I will not sell your PHI in the regular course of business. Any other use or disclosure not described in this Notice will be made only with your written authorization, which you may revoke in writing at any time.
IV. Your Rights With Respect to Your Health Information
- ·Right to Request Limits on Uses and Disclosures. You have the right to ask me not to use or disclose certain PHI for treatment, payment, or health care operations. I am not required to agree, and I may say no if I believe it would affect your health care.
- ·Right to Request Restrictions for Out-of-Pocket Expenses Paid in Full. You have the right to request restrictions on disclosures of your PHI to health plans for payment or health care operations purposes if the PHI pertains solely to a health care item or service that you have paid for out-of-pocket in full. I am required to agree to this type of restriction.
- ·Right to Choose How I Send PHI to You. You have the right to ask me to contact you in a specific way or to send mail to a different address. I will agree to all reasonable requests.
- ·Right to See and Get Copies of Your PHI. Other than psychotherapy notes, you have the right to inspect and receive an electronic or paper copy of your medical record and other PHI I hold about you. I will provide a copy or summary within 30 days of receiving your written request. I may charge a reasonable, cost-based fee.
- ·Right to Get a List of Disclosures I Have Made. You have the right to request a list of instances in which I have disclosed your PHI for purposes other than treatment, payment, or health care operations. I will respond within 60 days. The list will cover the prior six years unless you request a shorter period. The first request in any twelve-month period is free; I may charge a reasonable fee for additional requests.
- ·Right to Correct or Update Your PHI. If you believe your PHI contains a mistake or is incomplete, you have the right to request a correction or addition. I may deny your request, but I will tell you why in writing within 60 days.
- ·Right to Get a Paper or Electronic Copy of This Notice. You have the right to a paper copy of this Notice at any time. You may also request a copy by email. Even if you have agreed to receive this Notice electronically, you retain the right to request a paper copy.
- ·Right to Receive Notification of a Breach. You have the right to be notified following a breach of unsecured PHI that may have compromised your privacy or security.
V. My Duties
I am required by law to maintain the privacy and security of your PHI. I will notify you promptly if a breach occurs that may have compromised the privacy or security of your information. I will abide by the terms of this Notice. I will not use or disclose your PHI other than as described in this Notice or as otherwise permitted or required by law. I reserve the right to change the terms of this Notice. Any changes will apply to all PHI I maintain. The updated Notice will be available upon request at my office.
VI. How to File a Complaint
If you believe I have violated your privacy rights, you may file a complaint with me directly or with the U.S. Department of Health and Human Services, Office for Civil Rights. I will not retaliate against you for filing a complaint.
To file a complaint with me:
Kevin McKenzie, Psy.D. · McKenzie Psychology LLC · 1661 N. Swan Rd., Ste. 240, Tucson, AZ 85712 · 520-230-2530 · kevin@mckenziepsychology.com
To file a complaint with the federal government:
U.S. Department of Health and Human Services, Office for Civil Rights
200 Independence Avenue, S.W., Washington, D.C. 20201
Toll-free: 1-877-696-6775 · hhs.gov/ocr/privacy/hipaa/complaints
Effective date: May 1, 2026
