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Good Faith Estimate

We would like to let you know about your legal protection from unexpected medical bills. We want to inform you that you may receive services at lower cost from another provider within your insurance network.

 

Purpose of This Notice

The Federal “No Surprises Act" went into effect on January 1, 2022. The law was intended to prevent surprise medical bills when patients unknowingly obtain services from providers outside their health insurance network. Under the law, health care providers are required to give a good faith estimate of cost to patients who don’t have insurance or who are not using insurance. You are receiving this notice because your therapist is not in your insurance network, meaning he or she doesn’t have an agreement with your plan.

 

Standard Charges for Services in This Practice

Our current fee is always discussed before or during the initial session. Fees may be periodically adjusted with prior notice.

 

Estimate of Cost

You have the right to receive a good faith estimate explaining how much your medical care will cost. Because psychotherapy is usually a recurring service, the total cost is generally the number of sessions multiplied by the session fee. This estimate is based on one year of service. This estimate does not calculate or subtract the amount your health insurance may reimburse you. Some insurance plans may cover a portion of the charge. This is not a contract for services. You can discontinue services at any time. You are not obligated to pay any amount ahead of time. You are not obligated to pay the total estimated cost if you do not use the services.

 

Insurance Claims

Determining what portion of cost which your insurance may reimburse is your responsibility. Please let us know if you plan to submit a claim to your insurance for services. As a courtesy, we would be happy to generate a receipt—a statement or “superbill"—for you to submit to yourinsurance for out-of-network reimbursement.

 

Respecting Your Health Care Choices

If you use a network provider, your cost of services may be less than using an out-of-network provider. You may incur lower annual deductibles and higher rates of reimbursement for an in-network provider. You may choose to see a therapist as an out-of-network provider based on other factors, such as difficulty finding an in-network provider with availability for new patients or a decision that your work with a therapist in this practice will more quickly accomplish your goals.

 

Limitations of An Estimate of Cost

The estimate shows the cost of services that are reasonably expected for your health care needs. The actual total number of sessions is unknown at the outset. This estimate may be different, depending on a number of factors. The estimate does not include any unknown or unexpected costs that may arise during treatment. The actual cost is subject to change due to changes in the frequency and duration of services. Frequency and duration of services may vary based on complications or special circumstances that arise regarding your

issues or the severity of your symptoms, a new emerging condition, a change in diagnosis, changes in the frequency of appointments, social or environmental factors that may help or hinder your progress, your motivation and effort, and your decisions about treatment. The cost also may be adjusted based on financial need. Research indicates the average length of a course of psychotherapy may be from a few weeks to a few years. We respect your right to determine your goals for treatment and how long you would like to remain in therapy. We always welcome discussion about frequency and duration of services.

 

Appeals

You are welcome to dispute the charges if they are more than the estimate. You can ask them to update the bill to match the estimate, ask to negotiate the bill, or ask if financial assistance is available. If the actual cost of services in this office exceeds the estimate by more than $400, you are invited to discuss your concerns with the therapist about the increased amount. You may also initiate a dispute resolution process with the US Department of Health and Human Services within 120 calendar days from the date of the original bill. There is a $25 fee to use the process. If the agency reviewing your dispute agrees with you, you will have to pay the price on this estimate. If the agency disagrees with you, you will have to pay the higher amount. To start the process, go to www.cms.gov/nosurprises/consumers or call (800) 985-3059.

 

Informed Consent​

You are not required to sign this consent. You can discontinue services at any time. By seeing a therapist here, you are accepting that you may be paying more for services than going to an in-network provider. You are accepting that your insurance might not count some or all of the amount you pay toward your deductible or out-of pocket limit. Before deciding whether to agree to services, you are welcome to contact your insurance to get information about how much of these services are reimbursable or to find an in-network provider or facility. You are not required to receive care from your therapist. Except in an emergency, your health plan may require prior authorization (or other limitations) for certain services. This means you may need your plan’s approval that it will cover a service before you receive it. If prior authorization is required, ask your health plan about what information is necessary to get coverage. Please keep a copy of this page for your records.

 

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