No Surprises Act

This notice is to inform the patient of the No Surprises Act, in effect as of January 1st, 2022, and to provide the patient with a Good Faith Estimate. This act seeks to protect individuals from receiving surprise medical bills. The patient has the right to request a Good Faith Estimate from Nicole Franco Counseling, outlining the predicted costs of services. It is important to note that this is not a bill but an estimate of the potential, total costs of services.

Changes of services may arise due to the variable nature of counseling, such as a change in the patient’s presenting symptoms, diagnosis, or a change in the patient’s preference for services. Patient should be aware that they may choose to remain in therapy services longer than expected for reasons they cannot predict or choose to terminate services earlier than expected. Due to these variabilities, costs can fluctuate, and the patient has the right at any time to request an updated Good Faith Estimate from Nicole Franco Counseling. Nicole Franco Counseling will provide recommendations on the frequency and duration of counseling sessions that is most clinically beneficial for each patient, however, the patient reserves the right to accept or reject these recommendations. The patient is encouraged to discuss any concerns or questions regarding the Good Faith Estimate with Nicole Franco Counseling.

Disclaimer

This Good Faith Estimate shows the costs of items and services that are reasonably expected for your health care needs for an item or service. The estimate is based on information known at the time the estimate was created.

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 health care provider 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 have to pay the price on this Good Faith Estimate. If the agency disagrees with you and agrees with the health care provider or facility, you will have to pay the higher amount.

To learn more and get a form to start the process, go to www.cms.gov/nosurprises 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 (800) 368-1019.

Keep a copy of this Good Faith Estimate in a safe place or take pictures of it. You may need it if you are billed a higher amount.