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.
IMPORTANT: You aren’t required to sign this form and shouldn’t sign it if you didn’t have a choice of health care provider when you received 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.
You may have a copy of this form for your records.
You’re getting this notice because this provider, Deep River Counseling, PLLC isn’t in your health plan’s network. This means the provider doesn’t have an agreement with your plan. Getting care from this provider or facility could cost you more. If your plan covers the item or service you’re getting, 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 health care provider if you need help knowing if these protections apply to you.
If you sign this form, 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 towards your deductible and out of-pocket limit. Contact your health plan for more information.
You shouldn’t sign this form if you didn’t have a choice of providers when receiving care. For example, if a doctor was assigned to you with no opportunity to make a change. Before deciding whether to sign this form, you can contact your health plan to find an in-network provider or facility. If there isn’t one, your health plan might work out an agreement with this provider or facility, or another one.
Estimate of what you could pay
Out-of-network provider name: Deep River Counseling, PLLC, Mary Elder, MA., Ed.S., LCMHC_______
Total cost estimate of what you may be asked to pay:
• Review your detailed estimate.
• Call your health plan. Your plan may have better information about how much you will be asked to pay. You also can ask about what’s covered under your plan and your provider options.
• Questions about your rights? Contact NC Department of Health and Human Services
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.
Understanding your options: You can also get the items or services described in this notice from these providers who are in-network with your health plan: More information about your rights and protections visit https://www.cms.gov/nosurprises/consumers/new-protections-for-you for more information about your rights under federal law.
By signing, I give up my federal consumer protections and agree to pay more for out-of-network care. With my signature, I am saying that I agree to get the items or services from Deep River Counseling, PLLC, Mary Elder, LCMHC.
With my signature, I acknowledge that I am consenting of my own free will and am not being coerced or pressured. I also understand that:
• I’m giving up some consumer billing protections under federal law.
• I may get a bill for the full charges for these items and services or have to pay out-of-network cost sharing under my health plan.
• I was given a written notice on the date of your signature explaining that my provider isn’t in my health plan’s network, the estimated cost of services, and what I may owe if I agree to be treated by this provider.
• I got the notice either on paper or electronically, consistent with my choice.
• I fully and completely understand that some or all amounts I pay might not count toward my health plan’s deductible or out-of-pocket limit.
• I can end this agreement by notifying the provider or facility in writing before getting services.
IMPORTANT: You don’t have to sign this form. But if you don’t sign, this provider or facility might not treat you. You can choose to get care from a provider or facility in your health plan’s network.
Good Faith Estimate
Provider Name: Deep River Counseling, PLLC, Mary Elder, MA, Ed.S, LCMHC
License/#: NC LCMHC/#11232
Provider Address: 4521 Beaty Rd, Gastonia, NC 28056
Provider Phone #: (704) 237-0236
You are entitled to receive this “Good Faith Estimate” of what the charges could be for psychotherapy services provided to you. While it is not possible for a psychotherapist to know, in advance, how many psychotherapy sessions may be necessary or appropriate for a given person, this form provides an estimate of the cost of services provided. Your total cost of services will depend upon the number of psychotherapy sessions you attend, your individual circumstances, and the type and amount of services that are provided to you.
There may be additional items or services I may recommend as part of your care that must be scheduled or requested separately and are not reflected in this good faith estimate. This estimate is not a contract and does not obligate you to obtain any services from the provider(s) listed, nor does it include any services rendered to you that are not identified here. You have the right to initiate a dispute resolution process if the actual amount charged to you substantially exceeds the estimated charges stated in your Good Faith Estimate (which means $400 or more beyond the estimated charges). For questions or more information about your right to a Good Faith Estimate or the dispute process, visit https://www.cms.gov/nosurprises/consumers or call 1- 800-985-3059. The initiation of the patient-provider dispute resolution process will not adversely affect the quality of the services furnished to you.
The first appointment is a comprehensive clinical assessment with a fee of $185.00. The fee for a 52-minute psychotherapy visit (in person or via telehealth) is $125.00. Most clients will attend one psychotherapy visit per week, but the frequency of psychotherapy visits that are appropriate in your case may be more or less than once per week, depending upon your needs. Based on a fee of $125.00 per visit, the following are expected charges of psychotherapy services:
Initial Assessment 90-minutes sessions $185.00
Session fee for one 52-minute individual therapy $125.00
13 Weeks of Service (Approx. 3 Months) $1810
26 Weeks of Service (Approx. 6 months) $3435
39 Weeks of Service (Approx. 9 months) $5060
52 Weeks of Service (Approx. 12 Months) $6685
Additional sessions with family or crisis situations could add to the total cost.
This Good Faith Estimate is not intended to serve as a recommendation for treatment or a prediction that you may need to attend a specified number of psychotherapy visits. The number of visits that are appropriate in your case, and the estimated cost for those services, depends on your needs and what you agree to in consultation with your therapist. You are entitled to disagree with any recommendations made to you concerning your treatment and you may discontinue treatment at any time.