No Surprises Act Notice and Disclosures.

A Dash of Mindfulness Psychotherapy, PLLC

andrea.marburger@adashofmindfulness.com

512-856-7799

Effective Date: 01/01/2022

Under Section 2799B-6 of the Public Health Service Act, healthcare providers and healthcare facilities are required to inform individuals who are not enrolled in a plan (or coverage) or a Federal health care program or not are seeking to make a claim with their plan (or coverage), both orally and in writing, of their ability upon request (or at the time of scheduling health care items and services), to receive a “Good Faith Estimate” of expected charges.

Your Rights Under the Law

You have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost:

·        You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees.

·        You should receive a Good Faith Estimate in writing at least 1 business day before your medical service or item. You can also ask your healthcare provider, and any other provider you choose, for a Good Faith Estimate at any time during the course of treatment.

·        If you receive a bill that is at least $400 more than your current Good Faith Estimate, you can dispute the bill.

Your Good Faith Estimate

Under the law, healthcare providers need to give clients who do not have insurance, or who are not using insurance, an estimate of the bill for medical items and services that shows:

·        The client’s legal name and date of birth.

·        A description of the psychotherapy or other related service being furnished to the client.

·        An itemized list of services that are “reasonably expected” to be furnished.

·        Expected charges associated with each psychotherapy session or other service(s).

·        Your provider’s name, national provider number (NPI), tax identification number (TIN), and contact information.

·        The location(s) where services will be provided.

Disclaimers

There may be additional items or services that are recommended as part of the treatment that will be schedule separately and are not reflected in the good faith estimate. The information provided in the good faith estimate is only an estimate; and it does not require you to obtain psychotherapy or other services from your provider.

The Dispute Process

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. If this happens, federal law allows you to dispute (appeal) the bill. If you are billed for more than this Good Faith Estimate, you have the right to dispute the bill.

You may contact the healthcare provider or facility listed to let them know the billed charges are higher than the Good Faith Estimate. You can ask them to update the bill to match the Good Faith Estimate, ask to negotiate the bill, or ask if there is financial assistance available.

You may also start a dispute resolution process with the U.S. Department of Health and Human Services (HHS). If you choose to use the dispute resolution process, you must start the dispute process within 120 calendar days (about 4 months) of the date on the original bill.

There is a $25 fee to use the dispute process. If the agency reviewing your dispute agrees with you, you will only have to pay the price on this Good Faith Estimate. If the agency disagrees with you and agrees with the healthcare provider or facility, you will have to pay the higher amount.

To learn more and get a form to start the process, go to click the button below or call HHS at (800)-368-1019.

For questions or more information about your right to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprises or call CMS at 1-800-985-3059 .