Good Faith Estimate
*This notice is for self-pay/out-of-network patients only*
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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 (attached/below). 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, attached you will find a fee schedule for the services typically offered by 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 sign and date before your next appointment and return the signed document before your next appointment. If you have any questions, please don’t hesitate to ask.
Thank you very much,
Dr. Hayley Roberts
Yenza Therapy and Consulting
THE NO SURPRISES ACT
STANDARD NOTICE AND CONSENT DOCUMENTS
(OMB Control Number: 0938-1401)
SURPRISE BILLING PROTECTION FORM
The purpose of this document is to let you know about your protections from unexpected medical bills. It also asks whether you would like to give up those protections and pay more for out-of-network care.
You’re getting this notice because this provider or facility isn’t in your health plan’s network. This means the provider or facility doesn’t have an agreement with your plan.
Getting care from this provider or facility could cost you more.
If your plan covers the item or service you’re getting, federal law protects you from higher bills:
• When you get emergency care from out-of-network providers and facilities, or
• When an out-of-network provider treats you at an in-network hospital or ambulatory surgical center without your knowledge or consent.
Ask your health care provider or patient advocate if you need help knowing if these protections apply to you.If you sign this form, you may pay more because:
• You are giving up your protections under the law.
• You may owe the full costs billed for items and services received.
• Your health plan might not count any of the amount you pay towards your deductible and out- of-pocket limit. Contact your health plan for more information.
You shouldn’t sign this form if you didn’t have a choice of providers when receiving care. For example, if a doctor was assigned to you with no opportunity to make a change.
Before deciding whether to sign this form, you can contact your health plan to find an in-network provider or facility. If there isn’t one, your health plan might work out an agreement with this provider or facility, or another one.
See below for your cost estimate.
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Cost Estimate:
As an out-of-network/self-pay patient, you will discuss your fee with your Yenza Therapy and Consulting, LLC provider. That fee will be agreed upon by signing the initial paperwork. Once that fee has been determined, your total cost will be the number of sessions you have multiplied by that agreed upon fee.
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The following estimates are an example based on an agreed upon rate of $185
The amount below is only an estimate; it isn’t an offer or contract for services. This estimate shows the full estimated costs of the items or services listed. It doesn’t include any information about what your health plan may cover. This means that the final cost of services may be different than this estimate.
Contact your health plan to find out how much, if any, your plan will pay and how much you may have to pay.
Service code (CPT Code) Description: Fee for Service (Number of Sessions Will Be Determined as We Progress )
90834, 90837 Psychotherapy, 38-52 minutes, Psychotherapy ≥ 53 minutes: $185 (This fee is my hourly rate & used for all prorated calculations as indicated)
90832 Psychotherapy, 16-37 minutes: $115
98966-98968 Telephone Assessment & Management: Prorated based on the amount of time spent at hourly rate
98970-98972 Online Digital Evaluation & Mgt (Responding to Email & Text Messages): Prorated based on the amount of time spent at hourly rate
Cancelation Fee (Your Therapist Requires a 24-Hour Cancelation Fee): You are Responsible for the Fee of the Appointment Missed
Total Estimate: This Good Faith Estimate explains your therapist’s rate for each service provided. Your therapist will collaborate with you throughout your treatment to determine how many sessions and/or services you may need to receive the greatest benefit based on your diagnoses/presenting clinical concerns.