Surprise Billing Notification Form (Out of Network/Self-Pay Only) January, 2022

 

As of January 1st, 2022, the Centers for Medicare and Medicaid Services (CMS) instigated a new Federal rule to protect patients from unexpected medical bills and to increase transparency between health care clinicians and patients. This rule requires all medical and mental health clinicians (including LCSWs) to give a “good faith estimate” (GFE) to patients estimating the cost of services and how long services may last. 
 

I am also required to inform you that I am an “out-of-network” provider meaning that I do not submit claims to insurance and do not get paid by insurers.
 

By signing this form, you acknowledge the following:

• You have made a choice to not use your health insurance and seek a provider who may be in-network with your plan.

• You may or may not pay more for my services then your health insurance plan pays.

• You will pay me the full cost for each service I provide, as we have discussed.

 

Upon request, I can provide you what is known as a Superbill (receipt), which you can submit to your health insurance company. However, please be aware that your plan might not reimburse you, the payment may be of lesser amount than what you have paid me and/or they might not count any of the amount you pay towards your deductible and out-of-pocket limit.

Should you choose not to sign this form, please contact your health care plan directly for more information on “out-of-network” billing or to assist you in finding in-network provider, what is covered under your plan and other provider options.