Do you accept insurance?

SYV Therapy is committed to providing each patient with high-quality personalized care that isn’t limited by the constraints of insurance requirements, which is why our services are currently self-pay only and will continue to be our preferred method of payment. However, we do offer sliding-scale fees based on income and family size. We are also able to provide superbills for you to submit to your insurance but cannot guarantee their reimbursement. Please Note: We will be offering limited insurance coverage starting Winter 2024.

Do we need a referral or diagnosis to begin therapy?

Absolutely not! SYV Therapy recognizes that some children may not have the ability to obtain a referral, or have a previous diagnosis, yet still require support and treatment. We do not want anyone to be left out of getting help simply because of referral and/or diagnosis requirements.

Where do services take place?

Depending on your treatment plan, services will either take place in a local community park, in your home, or in school.

How long does treatment last?

The length of treatment and frequency of treatment will depend on the client and their needs. Dr. Kulikov-Ramirez will provide you with her recommendations after completing the initial assessment; however, there is no true way to know how long treatment will be needed. Ultimately, the parents and caregivers will decide when to stop services, unless the therapist recommends treatment be ended first.

What is the No Surprises Act/Good Faith Estimate?

Under Section 2799B-6 of the Public Health Service Act, mental health care providers are required to provide a “Good Faith Estimate” (GFE) to individuals not enrolled in an insurance plan or who plan to use their out of network benefits.  A good faith estimate enumerates the expenses you can reasonably expect to pay for psychotherapy services provided by me.

A GFE must be furnished within 1 business day of scheduling an appointment. If you schedule an appointment at least 10 business days in advance, you are entitled to receive the GFE within 3 business days after scheduling.  A GFE must be provided within 3 business days UPON REQUEST.

A GFE shows the costs of non-emergency psychotherapy services that are reasonably expected for your mental health needs and the estimate is based upon information known at the time the estimate was created.

A GFE does NOT include no-shows, late cancellations, or other services related to crisis care, which by definition are unexpected and cannot be predicted for the purpose of compiling a Good Faith Estimate in advance.

A GFE may also include consultations with client collateral contacts, fees related to paperwork requests, and other legal and administrative fees related to client care, when such items are scheduled in advance.

In my practice, I offer Good Faith Estimates that project out 12 months in advance. Essentially, your estimate will give you a reasonable idea what to expect in terms of therapy costs for one year, based on my current rates and the frequency of sessions that we mutually agree upon in advance.

As the GFE does not include any unknown or unexpected costs that may arise during treatment.  You could be charged more if complications or special circumstances occur.  If this happens, and your bill is $400 or more than the GFE, federal law allows you to dispute the bill with the Department of Health and Human Services.  You must start the dispute process within 120 calendar days of the date on the original bill.  There is a $25 fee to use the dispute process.

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

For questions or more information about your right to a Good Faith Estimate, visit

www.cms.gov/nosurprises

NOTICE OF PRIVACY PRACTICES

This notice describes how health information may be used and disclosed and how you can get access to this information. Please review it carefully.

1. OUR PLEDGE REGARDING HEALTH INFORMATION:

We understand that health information about you and your health care is personal. We 

are committed to protecting health information about you. Your provider will create a 

record of the care and services you receive from them.

This notice applies to all of the records of your care generated by this practice and will 

tell you about the ways in which we may use and disclose health information about you. We are required by law to:

• Make sure that protected health information (“PHI”) that identifies you is kept private.

• Give you this notice of our legal duties and privacy practices with respect to health information.

• Follow the terms of the notice that is currently in effect.

1. HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU:

The following categories describe different ways that we use and disclose health information.

For treatment payment, or Health Care Operations: Federal privacy rules (regulations) allow health care providers who have direct treatment relationship with the client to use or disclose the client’s personal health information without the patient’s written authorization, to carry out the health care provider’s own treatment, payment or health care operations. We may also disclose your protected health information for the treatment activities of any health care provider. This too can be done without your written authorization. For example, if a health care provider were to consult with another health care provider about your condition, we would be permitted to use and disclose your 

personal health information, which is otherwise confidential, in order to assist the health care provider in diagnosis and treatment of your condition.

Disclosures for treatment purposes are not limited to the minimum necessary standard. Because other health care providers need access to the full record and/or full and complete information in order to provide quality care. The word “treatment” includes, among other things, the coordination and management of health care providers with a third party, consultations between health care providers and referrals of a patient for health care from one health care provider to another. 

Certain uses and disclosures do not require your authorization:

• When disclosure is required by state or federal law, and the use or disclosure complies with and is limited to the relevant requirements of such law.

• For public health activities, including reporting suspected child abuse, elder, or dependent adult abuse, or preventing or reducing a serious threat to anyone’s health or safety.

• For health oversight activities, including audits and investigations.

• For judicial and administrative proceedings, including responding to a court or administrative order, although my preference is to obtain an authorization from you before doing so.

• For law enforcement purposes, including reporting crimes occurring on our premises.

• Appointment reminders and health related benefits or services.

1. CERTAIN USES AND DISCLOSURE REQUIRE YOU TO HAVE THE OPPORTUNITY TO OBJECT:

Disclosures to family, friends, or others. We may provide your PHI to a family member, friend, or other person that you indicate is involved in your care or the payment for your health care, unless you object in whole or in part. The opportunity to consent may be obtained retroactively in emergency situations.

1. YOU HAVE THE FOLLOWING RIGHTS WITH RESPECT TO YOUR PHI:

• The right to request limits on uses and disclosures of your PHI. You have the right to ask me not to use or disclose certain PHI for treatment, payment, or health care operations purposes. We are not required to agree to your request, and may say “no” if we believe it would affect your health care.

• The right to request restrictions for out-of-pocket expenses paid for 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 a health care service that you have paid for out-of-pocket in full.

• The right to choose how we send PHI to you. You have the right to ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address, and we will agree to all reasonable requests.

• The right to see and get copies of your PHI. Other than “session notes”, you have the right to get an electronic or paper copy of your medical record and other information that we have about you. We will provide you with a copy of your record, or a summary of it, if you agree to receive a summary, within 30 days of receiving your request, and we may charge a reasonable, cost based fee for doing so. We will deny a request to review or receive a copy of your records if we feel it is dangerous or not beneficial to your treatment and wellbeing.

All client information is treated with utmost respect, protection, and privacy. Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), you have certain rights regarding the use and disclosure of your protected health information. By signing below, you are acknowledging that you have received a copy of the HIPAA Notice of Privacy Practices.