(Meets MD, DE, FL, CT, TN, and DC Telehealth Requirements)

Release & Renew Mental Wellness, LLC**

Overview

We provide HIPAA-compliant telehealth services to clients located in:

• Maryland

• Delaware

• Florida

• Connecticut

• Tennessee

• Washington, DC

Clients must be physically located within one of these states at the time of the appointment.

Technology Requirements

Telehealth sessions are conducted through encrypted platforms. Clients must have:

• Reliable internet connection

• A private, confidential space

• A device with camera and audio

We may reschedule if privacy cannot be assured.

Informed Consent for Telehealth

Before receiving telehealth services, clients must provide:

• Verbal or written telehealth consent

• Identification verification

• Emergency location information for each session

Limitations of Telehealth

Telehealth may not be appropriate for:

• Emergencies or crisis situations requiring immediate intervention

• Clients without access to private or secure communication

• Certain assessments requiring physical presence

If telehealth becomes clinically inappropriate, an in-person referral will be recommended.

Confidentiality

We maintain the same privacy standards as in-person care. Clients agree not to:

• Record sessions

• Allow unauthorized individuals to overhear sessions

We do not record telehealth sessions under any circumstances.

Emergency Protocols

Clients must provide:

• Current physical location each session

• Emergency contact

• Local emergency service information

If safety concerns arise, appropriate emergency steps will be taken.

Cross-State Regulations

Surpassing federal telemedicine laws, we comply with:

• MD Telehealth Act

• DE Telemedicine Regulations

• FL Telehealth Provider Registration requirements

• CT Behavioral Health Telehealth Statutes

• TN Telehealth Modernization Act

• DC Telehealth Coverage Act

Release & Renew Mental Wellness, LLC
Effective Date: January 1, 2025

This Notice of Privacy Practices describes how medical and mental health information about you may be used and disclosed and how you can access this information. Please review it carefully.

If you have any questions, please contact us at:
admin@releaserenewmentalwellness.com

Your Privacy Rights

You have the right to:

1. Get an Electronic or Paper Copy of Your Medical Record

• You may ask to see or get a copy of your mental health record.

• We will provide a copy or summary within 30 days, for a reasonable fee.

• Certain psychotherapy notes require a separate authorization.

2. Ask Us to Correct Your Record

• If you believe information is incomplete or incorrect, you may request a correction.

• We may deny requests in certain circumstances but will explain our reasoning in writing.

3. Request Confidential Communication

You may request that we contact you at a different location, phone number, or via secure portal.

4. Ask Us to Limit What We Use or Share

You may request restrictions on the use or disclosure of your information.
We are not required to agree to all restrictions, but if we do agree, we will comply unless disclosure is required by law.

5. Get a List of Disclosures

You may request an accounting of disclosures made in the past six years, excluding:

• Treatment

• Payment

• Healthcare operations

6. Get a Copy of This Notice

You may request a digital or paper copy of this NPP at any time.

7. Choose Someone to Act for You

If you have a legal guardian, Power of Attorney, or healthcare proxy, we will verify their authority before sharing your information.

8. File a Complaint

You may file a complaint if you believe your privacy rights have been violated, with:

Release & Renew Mental Wellness
Email: admin@releaserenewmw.com

or

Office for Civil Rights
U.S. Department of Health & Human Services
www.hhs.gov/ocr/privacy

We will not retaliate against you for filing a complaint.

Effective: January 1, 2025

Your Rights

As a client of Release & Renew Mental Wellness, you have the right to:

• Be treated with dignity, respect, and cultural sensitivity

• Receive services free of discrimination

• Participate in your treatment plan

• Ask questions and obtain clear explanations of care

• Request reasonable accommodations

• Decline or withdraw from treatment at any time

• Access your records as permitted by law

• Confidentiality of your PHI

• Submit grievances or complaints without retaliation

• Receive timely responses to scheduling, billing, and administrative concerns

Your Responsibilities

For care to be effective and compliant, clients agree to:

Scheduling & Attendance

• Maintain consistent attendance at scheduled appointments

• Provide 24-hour notice for cancellations

• Understand that no more than 4 no-shows or late cancellations are allowed within a 12-month period

• Understand that exceeding the limit may result in discharge from care

Financial Responsibilities

• Pay copayments, coinsurance, deductibles, and balances when due

• Maintain valid insurance information at all times

• Notify the office immediately when:

  • Insurance changes

  • Coverage ends

  • A new card is issued

• Ensure Coordination of Benefits (COB) is current and on file

• Understand that no more than 2 missed copayments are permitted

  • Exceeding this may result in restricted scheduling or discharge

Clinical Engagement

• Provide accurate and honest information

• Participate actively in treatment recommendations

• Maintain a safe and respectful environment with staff

Effective: January 1, 2025

Release & Renew Mental Wellness follows transparent self-pay pricing as required by federal and state law.

Self-Pay Clients Are Responsible For:

• Full session fees at the time of service

• Fees for ESA letters, FMLA forms, and other documentation

• Fees for missed appointments or late cancellations

• Services not covered by insurance

Self-Pay Services Include (examples):

• ESA letters

• FMLA paperwork

• Bariatric evaluations

• Emotional or behavioral assessments

• Therapy or medication appointments (if not using insurance)

Payment Methods

We accept debit/credit cards and HSA/FSA (where applicable).

Effective: January 1, 2025

(No Surprises Act Compliance)

Under federal law, you have the right to receive a Good Faith Estimate explaining the expected cost of non-emergency services if you:

• Are uninsured

• Choose not to use insurance

• Request self-pay pricing

Your Good Faith Estimate Will Include:

• Expected number of sessions

• Estimated total cost of treatment

• Any additional administrative fees related to self-pay services

This is an estimate only, not a contract or guarantee.

To request a Good Faith Estimate:
Email: admin@releaserenewmentalwellness.com

Effective: January 1, 2025

To protect provider time and ensure access to care, the following policies apply:

Cancellation Requirements

• Clients must cancel or reschedule at least 24 hours before the appointment.

• Cancellations made with less than 24 hours may be charged a $75 late cancellation fee.

No-Show Policy

A no-show occurs when:

• The client does not attend the appointment

• The client arrives more than 10 minutes late

• The client cannot be seen due to incomplete forms or missing insurance information

Limit:

No more than 4 no-shows or late cancellations in a 12-month period.

Exceeding this limit may result in discharge from the practice.

Missed Copayments

Clients must pay copays on the day of service.

Limit:

No more than 2 missed copayments within a 12-month period.

Failure to meet this requirement may result in:

• Suspension of scheduling

• Required payment before booking future appointments

• Possible discharge

Insurance Requirements

Clients are responsible for:

• Keeping insurance information updated

• Notifying the office immediately of changes

• Ensuring Coordination of Benefits (COB) is on file

• Understanding that incorrect or outdated insurance may result in:

  • Claim denials

Fee for No-Show or Late Cancellation

The standard fee is $75.

Insurance does not cover missed appointment fees.