Dear Client and Prospective Client,
In compliance with the No Surprises Act that went into effect on January 1, 2022, healthcare consumers who don’t have insurance or who are not using their insurance have a right to receive a Good Faith Estimate for the total expected cost of any non-emergency medical items or services. The No Surprises Act also requires Restored Life Counseling to notify all healthcare consumers when services are rendered by a non-participating provider.
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 Restored Life Counseling isn’t in your health plan’s network and is considered out-of-network. This means Restored Life Counseling doesn’t have an agreement with your plan to provide services.
Getting care from Restored Life Counseling will likely cost you more than if you utilize your in-network services.
Additionally, Restored Life Counseling is 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 exact length and scope of treatment for our work together. Attached is the best estimate based on what is most typical at Restored Life Counseling. Please read and sign the Good Faith Estimate which follows. This estimate is provided in an effort to be as transparent as possible about your potential financial investment in services with Restored Life Counseling.
You may incur fees throughout your care with Restored Life Counseling that are in addition to costs associated with direct services. These fees include, but are not limited to:
- Late cancellation/no show fee: $180
- Medical records request: $45 per 15 minutes
- Extra paperwork: $45 per 15 minutes
- Consultation/Coordination of Care: $45 per 15 minutes
Primary Diagnosis and Diagnostic Code: To be determined. Fee per service will remain the same regardless of diagnosis.
Good Faith Estimate: This is information about how much you will be asked to pay. You also can ask about what’s covered under your plan and your provider options. Your treatment may or may not include all of the services listed below. Your treatment may or may not include the same quantities of each service listed below.
|Insurance Service Code||Description||Quantity||Fee||Subtotal|
|90791||50 Minute Intake Session||1||$ 250.00||$ 250.00|
|96416||General Psychological Assessment||1||$ 50.00||$ 50.00|
|96416||Problem Specific Psychological Assessments||3||$ 50.00||$ 150.00|
|90837||50 Minute Individual Session||52||$ 180.00||$ 9,360.00|
|90837+99354||100 Minute Individual Session||12||$ 360.00||$ 4,320.00|
|90847||Couple or family sessions||52||$ 180.00||$ 9,360.00|
|90853||Group Therapy||52||$ 90.00||$ 4,680.00|
Questions about this notice and estimate? Call Restored Life Counseling at 360-558-7663 or email firstname.lastname@example.org
More information about your rights and protections: Visit https://www.cms.gov/nosurprises for more information about your rights under federal law. You can also contact the Department of Health and Human Services with questions.
My initials and signature below indicate that I give up my federal consumer protections and agree to pay more for out-of-network care. In addition, I agree to get the services indicated from Restored Life Counseling.
With my signature, I acknowledge that I am consenting of my own free will and am not being coerced or pressured. I understand that I am giving up some consumer billing protections under federal law.
|I fully and completely understand that some or all amounts I pay might not count toward my health plan’s deductible or out-of-pocket limit.|
|I can end this agreement by notifying Restored Life Counseling as per the Consent Agreement terms in writing before getting services.|
|I will get a bill for the full charges for these items and services and not contribute to my in-network cost-sharing under my health plan.|