NO SURPRISES ACT
In compliance with the No Surprises Act that goes into effect January 1, 2022, all healthcare providers are required to notify clients of their Federal rights and protections against “surprise billing.” This Act requires that we notify you of your federally protected rights to receive a notification when services are rendered by an out-of-network provider, if a client is uninsured, or if a client elects not to use their insurance. Additionally, we are required to provide you with a Good Faith Estimate of the cost of services. It is difficult to determine the true length of treatment for mental health care, and each client has a right to decide how long they would like to participate in mental health care. Therefore, you will review all the fees with your therapist and we will collaborate with you on a regular basis to determine how many sessions you may need. It is a Federal requirement that we have each client sign this form to begin/resume treatment.
Please print, sign, and date the consent document below before your next appointment and return the signed document before the appointment. You can email the completed form to firstname.lastname@example.org. You can also have the document sent to you through your client portal by messaging your clinician and asking them to send it.
If you have any questions please reach out to our billing department at 302-295-1088 ext.706.