The No Surprises Act ensures that you don't incur surprise fees from healthcare providers. The following is a form that you will receive when you engage in services with me. It is also posted here for your financial protection and should be made available to you from other medical providers as well.
SURPRISE BILLING PROTECTION FORM
This document describes your protections against unexpected medical bills. It also asks if you’d like to give up those protections and pay more for out-of-network care.
IMPORTANT: You aren’t required to sign this form and shouldn’t sign it if you didn’t have a choice of health care provider before scheduling care. You can choose to get care from a provider or facility in your health plan’s network, which may cost you less.
If you’d like assistance with this document, ask your provider or a patient advocate. Take a picture and/or keep a copy of this form for your records.
You’re getting this notice because this provider or facility isn’t in your health plan’s network and is considered out-of-network. This means the provider or facility doesn’t have an agreement with your plan to provide services. Getting care from this provider or facility will likely cost you more.
If your plan covers the item or service you’re getting, federal law protects you from higher bills when:
You’re getting emergency care from an out-of-network provider or facility, or
An out-of-network provider is treating you at an in-network hospital or ambulatory surgical center without getting your consent to receive a higher bill.
Ask your health care provider or patient advocate if you’re not sure if these protections apply to you. If you sign this form, be aware that you may pay more because:
You’re giving up your legal protections from higher bills.
You may owe the full costs billed for the items and services you get.
Your health plan might not count any of the amount you pay towards your deductible and outof-pocket limit. Contact your health plan for more information.
Before deciding whether to sign this form, you can contact your health plan to find an in-network provider or facility. If there isn’t one, you can also ask your health plan if they can work out an agreement with this provider or facility (or another one) to lower your costs.
You are entitled to receive this Good Faith Estimate of your potential charges for psychotherapy services provided to you. While it is not possible for a psychotherapist to know, in advance, how many psychotherapy sessions may be necessary or appropriate for a given person, this form provides an estimate of the cost of services provided. Your total cost of services will depend upon the number of psychotherapy sessions you attend, your individual circumstances, and the type and amount of services that are provided to you. This estimate is not a contract and does not obligate you to obtain any services from the provider(s) listed, nor does it include any services rendered to you that are not identified here.
This Good Faith Estimate is not intended to serve as a recommendation for treatment or a prediction that you may need to attend a specified number of psychotherapy visits. The number of visits that are appropriate in your case, and the estimated cost for those services, depends on your needs and what you agree to in consultation with your therapist. You are entitled to disagree with any recommendations made to you concerning your treatment and you may discontinue treatment at any time.
The fee for a 45-minute psychotherapy visit (in person or via telehealth) ranges from $140-$205. Most clients will attend one psychotherapy visit per week, but the frequency of psychotherapy visits that are appropriate in your case may be more or less than once per week, depending upon your needs or desires. Based on a fee of $175 per visit, you can utilize the following equation to estimate your fees:
$175 per visit (x) ____ visits per week (x) ____ weeks = $_____
For example, for a client who attends psychotherapy sessions once per week for sixteen weeks, the estimated fees would be as follows:
$175 per visit (x) 1 visit per week (x) 16 weeks = $2,800
You have a right to initiate a dispute resolution process with U.S Department of Health and Human Services (HHS) if the actual amount charged to you substantially exceeds the estimated charges stated in your Good Faith Estimate (which means $400 or more beyond the estimated charges). If you choose to utilize this dispute option, you will be required to submit your claim within 120 calendar days from the date of your first bill. There is a fee to utilize the HHS dispute process. If the agency reviewing your claims agrees with you, you will have to pay the price of the good faith estimate. If the agency disagrees with you and agrees with your health care provider, you will be required to pay the full amount.
You are encouraged to speak with your provider at any time about any questions you may have regarding your treatment plan or the information provided to you in this Good Faith Estimate. Please visit www.cms.gov/nosurprises for more information or to start your dispute claim.
