Surprise Billing Protection Form

(Standard Notice and Consent Documents under the No Surprises Act, 45 CFR 149.410 and 149.420)

 The purpose of this information 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.

This notice is listed because this provider does not participate with insurance companies in-network. This means the provider doesn’t have an agreement with your plan.

 Getting care from this provider could cost you more. 

 If your plan covers behavioral health services, 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 or patient advocate if you need help knowing if these protections apply to you.

 If you agree to services with 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 towards your deductible and out-of-pocket limit. Contact your health plan for more information. 

You shouldn’t sign the Surprise Billing Protection 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 the Surprise Billing Protection 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. 

By signing the Surprise Billing Protection Form, you give up your federal consumer protections and agree to pay more for out-of-network care. 

 When you sign the Surprise Billing Protection Form, you are saying that you agree to receive counseling services from 

 Addie M. Brown, LPC, LMFT, NCC, Harbor Site Counseling, LLC

When you sign the Surprise Billing Protection Form, you acknowledge that you are consenting of your own free will and are not being coerced or pressured. You also understand that:

·      You are giving up some consumer billing protections under federal law.

·      You will get a bill for the full charges for these items and services, or have to pay out-of-network cost-sharing under your health plan.

·      You were given written notice explaining that this provider or facility isn’t in your health plan’s network, the estimated cost of services, and what you may owe if you agree to be treated by this provider or facility.

·      You received the notice either on paper or electronically, consistent with your choice.

·      You fully and completely understand that some or all amounts you pay might not count toward your health plan’s deductible or out-of-pocket limit.

·      You can end this agreement by notifying the provider or facility in writing before getting services.

 IMPORTANT: You don’t have to sign the Surprise Billing Protection 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.