Good Faith Estimate

Your Legal Protection: You have the right to receive a good faith estimate explaining how much your medical care will cost. We want to inform you that you may receive services at lower cost from another provider within your insurance network.

Purpose of This Notice

The Federal “No Surprises Act” went into effect on January 1, 2022. The law was intended to prevent surprise medical bills when patients unknowingly obtain services from providers outside their health insurance network.

Under the law, health care providers are required to give a good faith estimate of cost to patients who don’t have insurance or who are not using insurance. You are receiving this notice because your therapist is not in your insurance network, meaning he or she doesn’t have an agreement with your plan.

Standard Charges for Services

Fee Schedule — Current Fees: Our current fee schedule is listed in our consent forms. Fees may be periodically adjusted with prior notice.

Estimate of Cost

You have the right to receive a good faith estimate explaining how much your medical care will cost. Because psychotherapy is usually a recurring service, the total cost is generally the number of sessions multiplied by the session fee, and this estimate is based on a full year of service.

This estimate does not calculate or subtract any amount your health insurance may reimburse you — some insurance plans cover a portion of the charge, and figuring that out is separate from this estimate. This is not a contract for services: you’re free to discontinue treatment at any time, you’re not obligated to pay anything ahead of time, and you’re not obligated to pay the total estimated cost if you don’t end up using the services.

Insurance Claims

It’s your responsibility to determine what portion of the cost your insurance may reimburse. If you plan to submit a claim to your insurance for services, please let us know — as a courtesy, we’re happy to generate a receipt (sometimes called a “superbill”) that you can submit to your insurance for out-of-network reimbursement.

Respecting Your Health Care Choices

Using an in-network provider will typically cost you less than an out-of-network provider — in-network care often comes with lower annual deductibles and higher reimbursement rates. Even so, you may choose to work with a Group Therapy LA therapist as an out-of-network provider for reasons of your own, such as difficulty finding an in-network provider with availability, or a sense that working with a Group Therapy LA therapist will help you reach your goals more effectively. That choice is entirely yours to make.

Limitations of an Estimate

The estimate shows the cost of services that are reasonably expected for your health care needs. The actual total number of sessions is unknown at the outset. This estimate may be different, depending on a number of factors.

The estimate does not include any unknown or unexpected costs that may arise during treatment. The actual cost is subject to change due to changes in the frequency and duration of services. Frequency and duration may vary based on:

• Complications or special circumstances regarding your issues or the severity of your symptoms
• A new emerging condition or a change in diagnosis
• Changes in the frequency of appointments
• Social or environmental factors that may help or hinder your progress
• Your motivation and effort, and your decisions about treatment
• Financial need — the cost may be adjusted based on your individual circumstances

Research suggests that a course of psychotherapy can last anywhere from a few weeks to a few years. We respect your right to set your own goals for treatment and to decide how long you’d like to remain in therapy, and we always welcome a conversation about the frequency and duration of your sessions.

Appeals

You are welcome to dispute the charges if they are more than the estimate. You can:

• Ask us to update the bill to match the estimate
• Ask to negotiate the bill
• Ask if financial assistance is available

If the actual cost of services in this office exceeds the estimate by more than $400, you are invited to discuss your concerns with the therapist about the increased amount.

You may also initiate a dispute resolution process with the US Department of Health and Human Services within 120 calendar days from the date of the original bill. There is a $25 fee to use the process.

• If the agency reviewing your dispute agrees with you, you will have to pay the price on this estimate.
• If the agency disagrees with you, you will have to pay the higher amount.

To start the process, visit www.cms.gov/nosurprises/consumers or call (800) 985-3059.

Informed Consent

Please Note: You are not required to sign this consent. You can discontinue services at any time. By choosing to see a Group Therapy LA therapist, you’re accepting that you may pay more than you would with an in-network provider, and that your insurance might not count some or all of what you pay toward your deductible or out-of-pocket limit.

Before deciding whether to move forward, you’re welcome to contact your insurance company to find out how much of these services may be reimbursable, or to locate an in-network provider or facility. You are never required to receive care from your therapist.

Except in an emergency, your health plan may require prior authorization (or have other limitations) for certain services — meaning you may need your plan’s approval before it will cover a service. If prior authorization is required, ask your health plan what information is needed to get coverage.

Please keep a copy of this page for your records. If you have any questions about these charges or your rights, please contact us directly — we are always happy to discuss your individual situation.

Further Information

If you’d like to learn more about your rights under the No Surprises Act, these agencies can help:

• Centers for Medicare and Medicaid Services — (877) 267-2323 or www.cms.gov/nosurprises
• US Department of Health & Human Services — (877) 696-6775 or www.hhs.gov
• California Department of Insurance — (800) 927-4357 or www.insurance.ca.gov