Legal & Policy Page

The documents below apply to services provided directly by Twelve Oaks and Dr. Javin Hintz, including services provided by therapists contracted with Twelve Oaks.

Twelve Oaks is also home to independent practitioners who lease space within our community and operate their own separate businesses. If you are working with one of our community providers, please contact them directly for their privacy practices, informed consent, and billing policies, as these may differ from the documents below.

1. Notice of Privacy Practices (HIPAA) — How we protect and may use your health information.

2. Website Privacy Policy —  How we handle information collected through this website.

3. Website Terms of Service — Terms governing use of this website.

4. Right to Receive a Good Faith Estimate — Your right, as a self-pay client, to receive an estimate of costs before receiving services.

5. Informed Consent for Treatment — What to expect regarding the therapeutic relationship, confidentiality, and treatment policies. Provided and reviewed at intake. 

6. Twelve Oaks Client Referral Form  — Applicable for any formal referrals from other professionals.

This is the public "right to know" disclosure — not an individualized estimate. Individualized estimates are still provided directly to private-pay clients before scheduling, per standard practice.

You have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost. Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services.

You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees.

Make sure your health care provider gives you a Good Faith Estimate in writing at least 1 business day before your medical service or item. You can also ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule an item or service.

If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill.

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 https://www.cms.gov/initiatives/your-patient-rights/medical-bill-rights/know-your-medical-bill-rights/know-your-medical-bill-rights-when-not-using-insurance.