Good Faith Estimate
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Surprise Billing Protection Information
We want to ensure you're informed about your rights and protections regarding unexpected medical bills. This notice is intended to provide you with crucial information and offer you the choice to waive certain protections in favor of out-of-network care.
You are provided this notice because the provider or facility you are considering is not within your health plan's network, meaning they do not have an agreement with your plan. It's important to be aware that seeking care from such providers could result in higher costs.
Federal law provides protection in the following scenarios:
Emergency care from out-of-network providers and facilities.
Treatment by an out-of-network provider at an in-network hospital or ambulatory surgical center without your knowledge or consent.
If you have questions about whether these protections apply to your situation, please consult your healthcare provider or a patient advocate.
By signing this form, you may potentially incur additional costs because you are relinquishing your protections under the law. This means you may be responsible for paying the full amount for items and services received, and your health plan might not count these payments towards your deductible and out-of-pocket limit.
It's crucial not to sign this form if you did not have a choice of providers when receiving care, for instance, if a doctor was assigned to you without the option to change.
Before making a decision, consider reaching out to your health plan to find an in-network provider or facility. If none are available, your health plan may work out an arrangement with the provider or another facility.
Out-of-Network Provider: Hurt and Healing Behavioral Health and Wellness
Here are some steps to help you make an informed choice:
Review the detailed cost estimate attached for each service you will receive.
Contact your health plan to obtain precise information on your expected costs and coverage. You can also inquire about what is covered under your plan and your provider options.
If you have any questions regarding this notice and the estimate, feel free to call us at 252-652-6047.
For inquiries about your rights, please visit www.cms.gov/nosurprises
Prior Authorization and Care Management:
Unless it's an emergency, your health plan may require prior authorization for certain services. This means you must obtain your plan's approval before receiving these services. If prior authorization is needed, consult your health plan to understand the necessary information for coverage. You will be responsible for any services not covered by your plan, including late cancellation and no-show fees.
Understanding Your Options:
You can also receive the services described in this notice from in-network providers with your health plan.
For more information about your rights and protections, please visit https://www.cms.gov/nosurprises for comprehensive details on your rights under federal law.
By signing, you acknowledge:
You are giving up certain consumer billing protections under federal law.
You may receive a bill for the full charges for services or incur out-of-network cost-sharing under your health plan.
You were provided with written notice today, explaining that your provider or facility is not in your health plan's network, along with an estimated cost of services and potential financial obligations if you agree to be treated by this provider or facility.
You were given the notice either on paper or electronically, in line with your choice.
Some or all of the amounts you pay may not count towards your health plan's deductible or out-of-pocket limit.
You have the option to cancel this agreement by notifying the provider or facility in writing before receiving services.
You are not obligated to sign this form. However, if you choose not to sign, the provider or facility may decline to treat you. You have the option to receive care from a provider or facility within your health plan's network.
Remember to keep a copy or take a picture of this form. It contains essential information about your rights and protections.
Estimate of What You Could Pay:
The estimated costs provided are for reference only and are not a binding offer or contract for services. The final cost of services may differ from this estimate, as it does not consider your health plan's coverage. Contact your health plan to determine their contribution and your potential financial responsibility.
Only the services below pertain to you:
- Initial Appointment: $200 (1st Appointment)
- Weekly or Biweekly Psychotherapy w/ Psychologist: $200 (Service Code: 90837)
- Annual Diagnostic Assessment: $200 (Service Code: 90791)
- Weekly or Biweekly Psychotherapy w/ Therapist: $125 (Service Code: 90834)
- Weekly or Biweekly Family/Couples Psychotherapy: $200 (Service Code: 90847)
- Weekly or Biweekly Telehealth: $125 - $200
We hope this information helps you make informed decisions about your healthcare. If you have any questions or require further clarification, please don't hesitate to contact us. Your well-being is our priority.