The "No Surprises Act"

In compliance with the No Surprises Act that went 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 (see the following document). 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.  If you have any questions, please don’t hesitate to ask.

All information submitted is confidential and secured via HIPAA compliant encryption.