Insurances accepted, Anthem, Optima, Aetna, and private pay.

Information About Good Faith Estimates All my counseling clients have a right to receive a Good Faith Estimate per federal law as of January 1, 2022. A Good Faith Estimate enumerates the expenses you can reasonably expect to pay for your mental health care services provided by me and my counseling practice. The estimate is created based upon the information known at the time the estimate is first created. It does not include unknown or unexpected costs that may arise during treatment. It is possible you may incur more charges than the estimate enumerates if complications or special circumstances arise. If this happens, the federal law provides you a right to dispute your bill. If you are billed for $400 or more than your Good Faith Estimate, you have the right to dispute the bill. You may contact me directly to if you are billed charges that exceed the Good Faith Estimate. You can request for me to update your bill to match the Good Faith Estimate, request to negotiate the bill, or you may request information about financial assistance availability. You also have the right to initiate a dispute resolution process with the U.S. Department of Health and Human Services (HHS). If you choose to use the dispute resolution process, you must start the dispute process within 120 calendar days from the date on the original bill. There is a $25 fee to use the dispute process. If the dispute-reviewing agency agrees with you, you will be responsible for the amount provided on your Good Faith Estimate. If the agency disagrees with your dispute and agrees with the fees charged by me that exceed the Good Faith Estimate, you will have to pay the higher amount charged. To learn more visit www.cms.gov/nosurprises or call HHS at (800) 368-1019. Your estimate is not a contract. You are not obligated to receive services from me. My office can provide you with alternative referrals at your request at any time.

90791: Initial Psychotherapy intake (not timed) 90785: Add on Interactive Complexity (not timed) 90834: Ongoing therapy appointments (approx. 38-45 minutes) 90837: Ongoing therapy appointments (approx.. 53-60 minutes) 90847: Family/Couples appointments (approx.. 45-60 minutes) 90853: Group Psychotherapy (approx. 60 minutes)

Below are common diagnosis codes at MTG; however, the list is not exhaustive. With that said, diagnosis codes can change based on many factors. Please speak to your provider with any questions or concerns. Adjustment Disorder (F43.23) ADHD (F90.09) Autism Spectrum Disorder (F84.0) Mental Disorder, Not Otherwise Specified (F99) Depression (F32.9) Anxiety (F41.1) Bipolar Disorder (F31.9) Posttraumatic Stress Disorder (F43.10) MTG recognizes every individual’s mental health treatment journey is unique and personalized. How long you need to engage in mental health services and how often you attend sessions will be influenced by many factors, including, but not limited to: Your schedule and life circumstances Your provider’s availability Ongoing life challenges The nature of your specific challenges and how you address them Personal finances You and your provider will continually assess the appropriate frequency of services and will work together to determine when you have met your goals and are ready for discharge and/or a new "Good Faith Estimate" will be issued should your frequency or needs change.

Mountaintop Therapy Group is committed to the promotion of and action in support of equity, human rights, anti-hate, anti-racism, and social justice. This company, the owner Adam D. Williams and all who are employed and contracted by this company strive to oppose any actions of oppression. We are guided by the following principles: Ongoing self-examination with respect to dynamics of power and any/all assumptions and values that accompany various views, goals, and commitments. Sharing power, establishing and maintaining transparency about power differentials, collaborating when appropriate, and fostering the power of marginalized individuals and groups. Centering, amplifying and attending to the voices and experiences of marginalized groups and individuals. Raising awareness by attending to how individual or group difficulties may be shaped by political, societal, institutional, interpersonal, and other contextual power dynamics. Focusing on people’s strengths and engaging these strengths to address challenges, including working toward social change. Promoting self-determination with people this company works with and serves. This vision and these principles guide this company’s shared responsibility for ongoing efforts to enact commitment to diversity and social justice in our professional work.

Revised December 11, 2023 Translations: This Privacy Policy is executed in English. You agree and acknowledge that you have reviewed this Privacy Policy in English. Contacting Us: If you have questions regarding this Privacy Policy, its implementation, failure to adhere to this Privacy Policy and/or our general practices, please contact us at info@mountaintoptherapy.com, or send your comments to: Mountaintop Therapy Group Attention: Privacy Policy Personnel 302 Hickman Rd, Suite, 101 Charlottesville, Va 22911. Mountaintop Therapy Group will use commercially reasonable efforts to always respond and resolve any problem or question as promptly as possible.

The law requires authorization and consent for treatment, payment and healthcare operations. I may disclose PHI for the purposes of treatment, payment and healthcare operations with your consent. You have signed this general consent to care and authorization to conduct payment and health care operations, authorizing me to provide treatment and to conduct administrative steps associated with your care (i.e., file insurance for you) .Additionally, if you ever want me to send any of your protected health information of any sort to anyone outside my office, you will always first sign a specific authorization to release information to this outside party. A copy of that authorization formis available upon the request. The requirement of your signing an additional authorization form is an added protection to help insure your protected health information is kept strictly confidential. An example of this type of release of information might by your request that I talk to your child’s schoolteacher about his/her ADHD condition and what this teacher might do to be of help to your child. Before I talk to that teacher, you will have first signed the proper authorization for me to do so. There is a third, special authorization provision potentially relevant to the privacy of your records: my psychotherapy notes. In recognition of the importance of the confidentiality of conversations between psychotherapist -client in treatment settings, HIPAA permits keeping separate “psychotherapy notes” separate form the overall “designated medical record.” “Psychotherapy notes” cannot be secured by insurance companies nor can they insist upon their release for payment of services as has unfortunately occurred over the last two decades of managed mental health care. “Psychotherapy notes” are my notes “recorded in any medium by a mental health provider documenting and analyzing the contents of a conversation during a private, group or joint family counseling session and separated from the rest of the individual’s medical record.” “Psychotherapy notes” are necessarily more private and contain much more personal information about you hence, the need for increased security of the notes. “Psychotherapy notes” are not the same as your “progress notes” which provide the following information about your care each time you have an appointment at my office: medication prescriptions and monitoring, assessment/treatment start and stop times, the modalities of care, frequency of treatment furnished, results of clinical tests, and any summary of your diagnosis, functional status, treatment plan, symptoms, prognosis and progress to date. Certain payors of care, such as Medicare and Workers Compensation, require the release of both your progress notes and my psychotherapy notes in order to pay for your care. If I am forced to submit your psychotherapy notes in addition to your progress notes for reimbursement for services rendered, you will sign an additional authorization directing me to release my psychotherapy notes. Most of the time I will be able to limit reviews of your protected health information to only your “designated record set” which include the following: all identifying paperwork you completed when you first started your care here, all billing information, a summary of our first appointment, your mental status examination, your individualized, comprehensive treatment plan, your discharge summary, progress notes, reviews of you care by managed care companies, results of psychological testing, and any authorization letters or summaries of care you have authorized me to release on your behalf. Please note that the actual test questions or raw data of psychological tests, which are protected by copyright laws and the need to protect clients from unintended, potentially harmful use, are not part of your “designated mental health record.” You may, in writing, revoke all authorizations to disclose protected health information at any time. You cannot revoke an authorization for an activity already done that you instructed me to do or if the authorization was obtained as a condition for obtaining insurance and the insurer has the right to contest the claim under the policy.

HIPAA requires that I ensure that all those performing ancillary administrative service for my practice and refers to these people as “Business Associates” sign and enter into a HIPAA compliant Business Associate Agreement so that your privacy is ensured at all times.

By law, protected health information may be released without your consent or authorization for the following reasons: Child Abuse Suspected Sexual Abuse of a Child Adult and Domestic Abuse Health Oversight Activities (i.e., licensing board for Professional Counselors in Georgia) Judicial or Administrative Proceedings (i.e., if you are ordered here by the court) Serious Threat to Health or Safety (i.e., out “Duty to Warn” Law, national security threats) Workers Compensation Claims (if you seek to have your care reimbursed under Workers Compensation, all of your care is automatically subject to review by your employer and/or insurer(s). I never release any information of any sort for marketing purposes.

Adam D. Williams is the appointed “Privacy Officer” for Mountiantop Therapy Group per HIPAA regulations. If you have any concerns of any sort that my office may have compromised your privacy rights, please do not hesitate to speak to Adam immediately about this matter. You will always find us willing to talk to you about preserving the privacy of your protected mental health information. You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services. HIPAA provides client protections related to the electronic transmission of data (the transaction rule), the keeping and use of client records (“privacy rules”), and storage and access to health care records (“the security rules”). HIPAA applies to all health care providers, including mental healthcare, and providers and health care agencies throughout the country are now required to provide clients a notification of their privacy rights as it relates to their health care records. As you might expect, the HIPAA law and regulations are extremely detailed and difficult to grasp if you don’t have formal legal training. My Client Notification of Privacy Rights is my attempt to inform you of your rights in a simple yet comprehensive fashion. Please read this document as it is important you know what client protections HIPAA affords all of us. In mental health care, confidentiality and privacy are central to the success of the therapeutic relationship and as such, you will find I will do all I can to protect the privacy of your mental health records. If you have any questions about any of the matters discussed in this document, please do nothesitate toask me for further clarification. Adam D. Williams, LPC, RPT-S Privacy Officer Clinical Director and Owner

You have a right to the following: The right to request restrictions on certain uses and disclosures of your protected health information, which I may or may not agree to, but if I do, such restrictions shall apply unless our agreement is changed in writing; The right to receive confidential communications by alternative means and at alternative locations. For example, you may not want your bills sent to your home address so I will send them to another location of your choosing; The right to inspect and receive a copy of your protected health information in my designated mental health record set and any billing records for as long as protected health information is maintained in the records; The right to amend material in your protected health information, although I may deny an improper request and/or respond to any amendment(s) you make to your record of care; The right to an accounting of non-authorized disclosures of your protected health information; The right to a paper copy of notices/information from me, even if you have previously requested electronic transmission of notices/information; and The right to revoke your authorization of your protected health information except to the extent that action has already been taken. For more information on how to exercise each of these aforementioned rights, please do not hesitate to ask me for further assistance on these I am required by law to maintain the privacy of your protected health information and to provide you with a notice of your Privacy Rights and my duties regarding your PHI. I reserve the right to change my privacy policies and practices as needed with these current designated practices being applicable unless you receive a revision of my policies when you come for your future appointment(s). My duties as a Licensed Professional Counselor on these matters include maintaining the privacy of your protected health information, to provide you this notice of your rights and my privacy practices with respect to your PHI, and to abide by the terms of this notice unless it is changed and you are so notified. If for some reason you desire a copy of my internal policies for executing private practices, please let me know and I will get you a copy of these documents I keep on file for auditing purposes.

THIS NOTICE DESCRIBES HOW YOUR MENTAL HEALTH RECORDS MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE READ IT CAREFULLY. THIS POLICY IS POSTED ON OUR WEBSITE AT WWW.Mountiantoptherapygroup.com A PAPER COPY IS AVAILABLE UPON YOUR REQUEST FOR YOUR REVIEW AS WELL. Your Rights to Privacy under HIPAA Preamble: Communications between psychotherapists and their clients are privileged and, therefore, are protected from forced disclosure in cases arising under federal law. There is a difference between privileged conversations and documentation in your mental health Records are kept documenting your care as required by law, professional standards, and other review procedures. HIPAA very clearly defines what kind of information is to be included in your “Designated Medical Record” as well as some material, known as “Psychotherapy Notes” which is not accessible to insurance companies and other third-party reviewers and in some cases, not to the client himself/herself. HIPAA provides privacy protections about your personal health information, which is called “protected health information” (PHI) which could personally identify you. PHI consists of three(3) components: treatment, payment, and health care operations. Treatment refers to activities in which I provide, coordinate or manage your mental health care or other services related to your mental health care. Examples include a psychotherapy session, psychological testing, or talking to your primary care physician about your medication or overall medical condition. Payment is when I obtain reimbursement for your mental health care. The clearest example of this parameter is filing insurance on your behalf to help pay for some of the costs of the mental health services provided you. Health care operations are activities related to the performance of my practice such as quality assurance. In mental health care, the best example of health care operations is when utilization review occurs, a process in which your insurance company reviews our work together to see if your care is “really medically necessary.” The use of your protected health information refers to activities my office conducts for filing your claims, scheduling appointments, keeping records and other tasks within my office related to your care. Disclosures refer to activities you authorize which occur outside my office such as the sending of your protected health information to other parties (i.e., your primary care physician, the school your child attends).