Spencer Psychology

No Surprises Act

This document describes your protections against unexpected medical bills. It also asks if you would like to give up those protections and pay more for out-of-network care. You are not required to sign this form and should not 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 are getting this notice because this provider or facility is not in your health plan’s network and is considered out-of-network. This means the provider or facility does not have an agreement with your plan to provide services. Getting care from this provider or facility will likely cost you more. If your plan covers the item or service you’re getting, federal law protects you from higher bills when:

Ask your health care provider or patient advocate if you’re not sure if these protections apply to you. If you sign this form, be aware that you may pay more because:

Before deciding whether to sign this form, you can contact your health plan to find an in-network provider or facility. If there is not one, you can also ask your health plan if they can work out an agreement with this provider or facility (or another one) to lower your costs. This is called a ‘single case agreement.’ (*Please be aware that Spencer Psychology does not contract with out of network insurance for single case agreements.)

Summary

In summary, this means Spencer Psychology will not be billing your insurance, and will expect to collect the full fee from you. If you choose to file your out of network insurance on your own, you may not receive any reimbursement or credit towards your deductible from your insurance due to these or other reasons:

Good Faith Estimate

Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services.

For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises

Our self-pay rate is $150 per 60 minutes, our standard session length. Our clients are typically seen weekly or biweekly in the early stages of therapy, then space out sessions as they improve. The duration and frequency of therapy is a collaborative decision between you and your therapist based on your preferences for intensity of treatment, ongoing diagnosis, progress, goals, budgets and schedules. Many clients have more than one issue they wish to address, and will take breaks before starting to work in a new area. This is all under the client’s control.

Services are scheduled at your request, with no hidden costs. The Good Faith Estimate is not a contract, and you may discontinue at any point or change frequency. If you request a specialty service such as an EMDR intensive, you will be given that cost prior to the service being scheduled. If you choose to be seen weekly for one hour, your cost will be $600 per month without insurance, $3600 if you choose to be seen weekly for six months and $7500 if you choose to be seen weekly for a full year.

The estimated costs are valid for 12 months from the date of the Good Faith Estimate. This estimate shows the estimated costs of the items or services listed. It doesn’t include any information about what your health plan may cover, so the final price could be different. If you have health insurance, and the services you are seeking are covered by your health care plan, you may be able to get the items or services described in this notice from providers who are in-network with your health plan.

Client Name:  
Client Date of Birth:  

Diagnosis: No Diagnosis or Condition
Diagnosis Code: Z03.89

Provider: Spencer Psychology
Practice Address: 482 S. Landmark Avenue Bloomington IN 47404

Group NPI:
1932331345
Tax ID: 202391435

Date of Service Service Code Description Estimated amount to be billed
TBA 90791 Intake $175.00
TBA 90837 1 hour session (standard) $150.00
TBA 90834 45-minute session $112.50
TBA 90846 Family session without client present $150.00
TBA 90847 Family session with Client present $150.00
    Estimate of what you may owe: See Above

You can print your copy of this agreement by clicking “print” below. You can also contact us if you prefer an emailed/ US mailed copy, and call us at 812-333-8474 if you have any questions or need assistance.

Disclaimers

With your signature, you acknowledge that you have read the above information, have had an opportunity to ask questions, and agree to engage in the service(s) listed above.

IMPORTANT: You don’t have to sign this form. If you don’t sign, Spencer Psychology may not be able to treat you, but you can choose to get care from a provider or facility that’s in your health plan’s network.

Client Name:  

Electronic Signature of Client/Parent/Guardian:  

Date: