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:
- You’re getting emergency care from an out-of-network provider or facility, or
- An out-of-network provider is treating you at an in-network hospital or ambulatory surgical center without getting your consent to receive a higher bill.
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:
- You’re giving up your legal protections from higher bills.
- You may owe the full costs billed for the items and services you get.
- 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.
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:
- Your provider may not write notes or use codes that would meet the medical necessity requirement for insurance.
- Your provider may be providing a service or diagnosis that does not meet the medical necessity requirement for insurance reimbursement.
- Your insurance may require preauthorization for mental health services. Spencer Psychology does not obtain preauthorization for out of network insurance policies.
- You may have insurance that you cannot file yourself, and is required to be filed by the provider. You understand that by waiving your benefits, Spencer Psychology will not file your insurance for you, even if the insurance company does not allow clients to file it themselves.
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.
- You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services.
- You have the right to have this estimate in writing least 1 business day before your medical service. You can also ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule a service.
- If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill. (Please note if you request additional services or increased frequency after the estimate, this will not have been included in the original estimate).
- Make sure to save a copy or picture of your Good Faith Estimate, or print it out.
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:
Enter client/child name
Client Date of Birth:
Enter Date of Birth
Diagnosis:
No Diagnosis or Condition
Diagnosis Code:
N/A
Provider:
Spencer Psychology
Practice Address:
482 S. Landmark Avenue Bloomington IN 47404
Group NPI:
1932331345
Tax ID:
202391435
| Date of Service |
CPT/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 |
| TBA |
90832 |
30-minute session |
$75.00 |
| TBA |
90785 |
Add-on play therapy |
$15.00 |
| TBA |
non-standard* |
Couples/Marital Counseling - 60 minutes |
$150.00 |
| TBA |
non-standard* |
Couples/Marital Counseling - 75 minutes |
$187.50 |
| TBA |
non-standard* |
EMDR Weekend Intensive |
$2100.00 |
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Estimate of what you may owe: |
See Above |
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*Our EMDR Weekend Intensive and Couples/Marital Counseling are non-covered services by insurance, and do not have national standard CPT codes assigned. They are not considered usual mental health services by insurance.
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
- This Good Faith Estimate shows the costs of items and services that are reasonably expected.
- 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.
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:
Enter client/child name
Electronic Signature of Client/Parent/Guardian:
Enter your full name
Date: