The No Surpise Act Standard Notice & Consent
OMB Control Number: 0938-1401
NO SURPRISE BILLING PROTECTION FORM
The purpose of this document is to let you know about your protections from unexpected medical bills. It also asks whether you would like to give up those protections and pay more for out-of-network care.
When you express interest in services, You will receive a notice such as this one stating that the provider(s) at Authentic Counseling are not in your health plan’s network. This means the provider does not have an agreement with your insurance plan, and is considered “Out-Of-Network”. Getting care from this provider could cost you more.
If your plan covers the service that you are receiving, federal law protects you from higher bills:
• When you get emergency care from out-of-network providers and facilities, or
• When an out-of-network provider treats you at an in-network hospital or ambulatory surgical center without your knowledge or consent.
Ask your healthcare provider if you need help knowing if these protections apply to you.
If you choose to receive services from this provider, you may pay more because:
• You are giving up your protections under the law.
• You may owe the full costs billed for items and services received.
• Your health plan might not count any of the amount you pay toward your deductible and/or out-of-pocket limit.
Contact your health insurance plan for more information.
Good Faith Estimate
Total cost estimate of what you could be asked to pay:
Once you express interest in services, you will receive a "Good Faith Estimate, outlining a cost estimate for each recommended service. The estimate you receive is NOT a contract. It is your right to determine your goals for treatment and how long you would like to remain in therapy. Please see the breakdown of possible fees on this website's
Review your estimate.
Call your health plan. Your plan may have better information about whether or how much of these services are reimbursable.
Questions about this notice and estimate? Call 267-499-4419 or write to Authenticcounseling@protonmail.com.
Questions about your rights? Contact the Pennsylvania Secretary of State at 717-787-6458.
Prior authorization or other care management limitations:
Except in an emergency, your health plan may require prior authorization (or other limitations) for certain items and services. This means you may need your plan’s approval that it will cover an item or service before you get them. If prior authorization is required, ask your health plan about what information is necessary to get coverage.
For more information about your rights and protections:
Visit: https://www.cms.gov/files/document/model-disclosure-notice-patient-protections-against-surprise-billing-providers-facilities-health.pdf for more information about your rights under federal law.