GOOD FAITH ESTIMATE DISCLAIMER
Disclaimer for Good Faith Estimate for Cash Pay and Out of Network Clients
Effective January 1, 2022, a ruling went into effect called the "No Surprises Act" which requires practitioners to provider a "Good Faith Estimate" about out-of-network care. The Good Faith Estimate works to show the cost of items and services that are reasonably expected for your health care needs for an item or service, a diagnosis, and a reason for therapy. The estimate is based on information known at the time the estimate was created. The Good Faith Estimate does not include any unknown or unexpected costs that may arise during treatment. You could be charged more if complications or special circumstances occur and will be provided a new "Good Faith Estimate" should this occur.
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 might cost you more than utilizing your in-network insurance benefits. Under Section 2799B-6 of the Public Health Service Act, health care providers and health care facilities are required to inform individuals who are not enrolled in a plan or coverage or a Federal health care program, or not seeking to a claim with their plan or coverage both orally and in writing of their ability, upon request or at the time of scheduling health care items and services, to receive a “Good Faith Estimate” (GFE) of expected charges. The GFE shows the costs of items and services that are reasonably expected for services provided by TTC. The estimate is based on information known at the time the estimate was created. It does not take into account any reimbursement that you may receive as a result of out of network benefits. The Good Faith Estimate does not include any unknown or unexpected costs that may arise during treatment. You could be charged more if complications or special circumstances occur.
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 would prefer to use services with an in-network provider for your care. You can choose to get care from a provider or facility in your health plan’s network, which may cost you less. Prior to the onset of service, contact your health insurance plan to discuss your potential out-of-network mental health benefits, including your deductible and co-insurance, if You may also start a dispute resolution process with the U.S. Department of Health and Human Services (HHS). If you choose to use the dispute resolution process, you must start the dispute process within 120 calendar days (about 4 months) of the date on the original bill. There is a $25 fee to use the dispute process. If the agency reviewing your dispute agrees with you, you will have to pay the price on this Good Faith Estimate. If the agency disagrees with you and agrees with the health care provider or facility, you will have to pay the higher amount. To learn more and get a form to start the process, go to www.cms.gov/nosurprises or call 800-985-3059. For questions or more information about your right to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprises or call 800-985-3059. Keep a copy of this Good Faith Estimate in a safe place or take pictures of it. You may need it if you are billed a higher amount. For more information about your rights and protections under Federal Law, visit www.cms.gov/nosurprises/consumers. If you are billed $400 or more than your Good Faith Estimate, you have the right to dispute the bill. You may contact the health care provider or facility listed to let them know the billed charges are higher than the Good Faith Estimate. any. You also can ask about what’s covered under your plan and your provider options. You will receive a Good Faith Estimate for the cost of services at Middletown Counseling. Review your detailed estimate and proceed with services only after reviewing and signing the document.
You may also start a dispute resolution process with the U.S. Department of Health and Human Services (HHS). If you choose to use the dispute resolution process, you must start the dispute process within 120 calendar days (about 4 months) of the date on the original bill. There is a $25 fee to use the dispute process. If the agency reviewing your dispute agrees with you, you will have to pay the price on this Good Faith Estimate. If the agency disagrees with you and agrees with the health care provider or facility, you will have to pay the higher amount.
To learn more and get a form to start the process, go to www.cms.gov/nosurprises or call 800-985-3059. For questions or more information about your right to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprises or call 800-985-3059. Keep a copy of this Good Faith Estimate in a safe place or take pictures of it. You may need it if you are billed a higher amount. For more information about your rights and protections under Federal Law, visit www.cms.gov/nosurprises/consumers.
Disclaimer for Good Faith Estimate for Cash Pay and Out of Network Clients
Effective January 1, 2022, a ruling went into effect called the "No Surprises Act" which requires practitioners to provider a "Good Faith Estimate" about out-of-network care. The Good Faith Estimate works to show the cost of items and services that are reasonably expected for your health care needs for an item or service, a diagnosis, and a reason for therapy. The estimate is based on information known at the time the estimate was created. The Good Faith Estimate does not include any unknown or unexpected costs that may arise during treatment. You could be charged more if complications or special circumstances occur and will be provided a new "Good Faith Estimate" should this occur.
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 might cost you more than utilizing your in-network insurance benefits. Under Section 2799B-6 of the Public Health Service Act, health care providers and health care facilities are required to inform individuals who are not enrolled in a plan or coverage or a Federal health care program, or not seeking to a claim with their plan or coverage both orally and in writing of their ability, upon request or at the time of scheduling health care items and services, to receive a “Good Faith Estimate” (GFE) of expected charges. The GFE shows the costs of items and services that are reasonably expected for services provided by TTC. The estimate is based on information known at the time the estimate was created. It does not take into account any reimbursement that you may receive as a result of out of network benefits. The Good Faith Estimate does not include any unknown or unexpected costs that may arise during treatment. You could be charged more if complications or special circumstances occur.
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 would prefer to use services with an in-network provider for your care. You can choose to get care from a provider or facility in your health plan’s network, which may cost you less. Prior to the onset of service, contact your health insurance plan to discuss your potential out-of-network mental health benefits, including your deductible and co-insurance, if You may also start a dispute resolution process with the U.S. Department of Health and Human Services (HHS). If you choose to use the dispute resolution process, you must start the dispute process within 120 calendar days (about 4 months) of the date on the original bill. There is a $25 fee to use the dispute process. If the agency reviewing your dispute agrees with you, you will have to pay the price on this Good Faith Estimate. If the agency disagrees with you and agrees with the health care provider or facility, you will have to pay the higher amount. To learn more and get a form to start the process, go to www.cms.gov/nosurprises or call 800-985-3059. For questions or more information about your right to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprises or call 800-985-3059. Keep a copy of this Good Faith Estimate in a safe place or take pictures of it. You may need it if you are billed a higher amount. For more information about your rights and protections under Federal Law, visit www.cms.gov/nosurprises/consumers. If you are billed $400 or more than your Good Faith Estimate, you have the right to dispute the bill. You may contact the health care provider or facility listed to let them know the billed charges are higher than the Good Faith Estimate. any. You also can ask about what’s covered under your plan and your provider options. You will receive a Good Faith Estimate for the cost of services at Middletown Counseling. Review your detailed estimate and proceed with services only after reviewing and signing the document.
You may also start a dispute resolution process with the U.S. Department of Health and Human Services (HHS). If you choose to use the dispute resolution process, you must start the dispute process within 120 calendar days (about 4 months) of the date on the original bill. There is a $25 fee to use the dispute process. If the agency reviewing your dispute agrees with you, you will have to pay the price on this Good Faith Estimate. If the agency disagrees with you and agrees with the health care provider or facility, you will have to pay the higher amount.
To learn more and get a form to start the process, go to www.cms.gov/nosurprises or call 800-985-3059. For questions or more information about your right to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprises or call 800-985-3059. Keep a copy of this Good Faith Estimate in a safe place or take pictures of it. You may need it if you are billed a higher amount. For more information about your rights and protections under Federal Law, visit www.cms.gov/nosurprises/consumers.