No Surprises Act
Good Faith Estimates for Self Pay/Out of Network
In compliance with the No Surprises Act that went into effect January 1, 2022, I am required to notify all healthcare consumers of your Federal rights and protections against “surprise billing”.
This Act requires that I notify you of your federally protected rights to receive a notification when services are rendered by a non-participating provider and provide options to receive care from an in-network provider if one is available. I will provide this electronically or by paper depending on your preference at the first appointment.
Additionally, I am required to provide you with a Good Faith Estimate of the cost of services for the duration of treatment. It is difficult to determine the true length of treatment for mental health care, but I will discuss the best estimate based on the average length of treatment.
I will also provide a list of fees (direct counseling fees are specified under services as well) that may incur throughout your care that are in addition to direct counseling services and fees. These fees may occur due to the following (not an exhaustive list):
Late cancellation/no show fee
Medical records request
Completion of documents (FMLA, disability, summary letters, etc)
Consultation (IEP meetings, coordination of care, etc)
Subpeona (request to testify)
If you have additional questions regarding your anticipated Out of pocket costs or cost-sharing benefits please contact your health insurance plan or counselor if you do not have health insurance.
►Review your detailed estimate. See provided documentation for a cost estimate for each item or service you’ll get.
►Call your health plan. Your plan may have better information about how much you will be asked to pay. You also can ask about what’s covered under your plan and your provider options.
►Questions about this notice and estimate? Contact your counselor.
►Questions about your rights? Contact the Department of Health and Human Services