No Surprise Act

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The No Surprise Act that goes into effect on January 1, 2022, is in compliance with the Federal rights and protections against “surprise billing.” All healthcare providers are required to provide clients with their a No Surprise Act.

This Act requires 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.

The Good Faith Estimate does not obligate clients to obtain services. It is only an estimate for services rendered; the actual service charge may differ. The Good Faith Estimate does not include unknown and/or unanticipated costs such as No show/late cancelation fees, record/s requests, letter-writing (s), legal fee(s), court attendance, professional collaborations. The fees for these services are discussed in your treatment service agreement.

We are also required to provide you with a Good Faith Estimate of the cost of services (attached.) Every client is different mental health care needs thus it is difficult to determine the frequency or length of treatment for treatment. To this end, please find attached a fee schedule for services typically offered by your therapist. We will continue collaborating with you to determine how many sessions you may need.

Initial diagnostic Assessment 90791 (first session) $150

Individual Sessions: $120 X 4 = $480

Couples Session: $130 X 4 = $520

Family Sessions: $150 X 4 = $600

If you participate in therapy for a longer period, your total estimated charges will increase. Each client’s therapy journey is different and the frequency in which you engage in therapeutic treatment is determined by many factors such as:

•   Scheduling (yours and therapists)
•   Life Transitions
•   Life Challenges
•   Personal finances

We are also required by the Federal government to obtain signatures from clients to begin and /or resume treatment. Please sign and return this document before your next session. If you have any questions, please don’t hesitate to ask.

For more information about the Good Faith Estimate, please visit www.ams.go/nosurprises or call (800) 368- 1019.

Important: You are not required to sign this form. But due to the Federal requirement, the providers at Mine Counseling PLLC may not be able to work with you without a signed document. You have the right to obtain care from a provider that is in your network.

By signing the document, clients affirm that they read this document in its entirety and understand what they are agreeing to in this Good Faith Estimate and No Surprise Act.

Nkem Chinwah. MS., LMFT, LPC, & Life Coach 

LMFT # 202918, LPC # 78629