The No Surprises Act Standard Notice and Consent

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. If you’d like assistance with this document, ask Molly Gotheridge, MA, LMHC, or a patient advocate. Take a picture and/or keep a copy of this form for your records.

RECEIVING CARE AND UNDERSTANDING COST

Receiving care from Gotheridge Counseling, LLC could cost you more. Ask Molly Gotheridge, MA, LMHC, or a patient advocate 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 counselor 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 another provider or facility.

Out-of-Network Provider/Facility Name:

Molly Gotheridge, MA, LMHC/Gotheridge Counseling, LLC

TOTAL COST ESTIMATE OF WHAT YOU MAY BE ASKED TO PAY

It is your ethical right to determine your goals for treatment and how long you would like to remain in therapy unless you are pursuing mandatory treatment. Please see the breakdown of possible costs later in this document.

• Review your detailed estimate.

• Call your health plan. Your plan may have better information about how much of these services are reimbursable. You can also ask about what’s covered under your plan and your provider options.

• Questions about this notice estimate? Contact Molly Gotheridge, MA, LMHC

THE NO SURPRISES ACT STANDARD NOTICE AND CONSENT

Questions about your rights? Contact the Florida Board of Clinical Social Work, Marriage &

Family Therapy, and Mental Health Counseling at

https://floridasmentalhealthprofessions.gov or 850.488.0595

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 receive them. If prior authorization is required, ask your health plan about what information is necessary to receive coverage.

Understanding Your Options

You can also obtain the items or services described in this notice from these providers who are in-network with your health plan:

• Orlando Health Medical Group Behavioral Health – https://www.orlandohealth.com/physician-practices/orlando-health-behavioral-group

• Advent Health Orlando Behavioral Health – https://www.adventhealth.com/hospital/adventhealth-orlando/behavioral-health

• Aspire Health Partners – https://aspirehealthpartners.com/services-cost/

More Information About Your Rights and Protections

For more information about your rights under federal law, visit:

• https://www.hhs.gov

• https://www.cms.gov/files/document/model-disclosure-notice-patient-protections-against-surprise-billing-providers-facilities-health.pdf

Document Information & Your Rights

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 receive the items or services from Gotheridge Counseling, LLC. 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 receive 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 day of signing, explaining that my provider or facility 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 Gotheridge Counseling, LLC have been provided to me.

• I received 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 Gotheridge Counseling, LLC in writing before receiving services.

IMPORTANT: You don’t have to sign this form; however, if you don’t sign, the provider or facility might not treat you. You can choose to receive care from a provider or facility in your health plan’s network.

Good Faith Estimate and List of Service Fees

The amount below is only an estimate; it isn’t an offer or contract for services. This estimate shows the full estimated costs of the items or services listed. It doesn’t include any information about what your health plan may cover. This means that the final cost of services may be different than this estimate.

Contact your health plan to find out how much, if any, your health plan will pay and how much you may have to pay.

Please note, the number of sessions will be determined as we progress.

- Case management, each 15 minutes (Code: T1016) (Rate: $45)

- Psychiatric Diagnostic Evaluation (Code: 90791) (Rate: $175)

- Family psychotherapy (conjoint psychotherapy) (with patient present) (Code: 90847) (Rate: $150)

- Family psychotherapy (without the patient present) (Code: 90846) (Rate: $150)

- Group psychotherapy (other than of a multiple-family group) (Code: 90853) (Rate: $150)

- Psychotherapy, 30 minutes with patient and/or family member (Code: 90832) (Rate: $75)

- Psychotherapy, 45 minutes with patient and/or family member (Code: 90834) (Rate: $150)

- Psychotherapy, 60 minutes with patient and/or family member (Code: 90837) (Rate: $150)

- Legal Involvement (Code: None) (Rate: $250)

- Psychological Testing (Code: 96130) (Rate: $150 pro-rated based on time spent)

- Telephone Assessment & Management (According to the CPT manual, the codes 98966, 98967, 98968 are for 5 10 Minutes, 11-20 Minutes, and 21-30 Minutes, respectively) (Rate: $28, $35, $70, respectively)

- Online Digital Evaluation & Management (Responding to Email & Text Messages - According to the CPT manual, the codes 98970, 98971, 98972 are for 5-10 Minutes, 11-20 Minutes, and 21-30 Minutes, respectively) (Rate: $28, $35, $70, respectively)

- Cancellation Fee (Requires a 24-Hour Notice, less than 24 hours will result in either a late cancellation fee or a no show fee) (Rate: $75 for Late Cancel; $100 for No Show)

- Production of Records (Code: None) (Rate: Pro-rated based on the amount of time spent at the standard rate).

- Legal Fees (This charge applies to all aspects of the court process; including, but not limited to travel to and from the courthouse, time in court, waiting for the court hearing, preparation of documents, depositions, hearings, trial, court-ordered appearances, litigation, etc.) ($250 per hour, for every hour outside of the office to include travel time, with a minimum of four hours or $1,000)

Total Estimate

This Good Faith Estimate explains Gotheridge Counseling, LLC's rate for each service provided. Gotheridge Counseling, LLC will collaborate with you throughout your treatment to determine how many sessions and/or services you may need in order to receive the greatest benefit based on your diagnosis(es)/presenting clinical concerns.