No Surprise Billing Act
Counseling208, LLC DBA Susan Barker Therapy | 208-314-0555
Surprise Billing Protection Form (Good Faith Estimate)
This document describes your protections against unexpected medical bills. It also asks if you’d 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 before scheduling care. You can choose to get care from a provider in your health plan’s network, which may cost you less.
If you have any questions, please reach out to me for support. Take a picture and/or keep a copy of this form for your records.
You’re getting this notice because I am not in your health plan’s network and considered out-of-network. This means I don’t have an agreement with your plan to provide services. Getting care outside your network will likely cost you more.
If your plan covers the service you’re getting, federal law protects you from higher bills when:
You’re getting emergency care from an out-of-network provider or facility, or
An out-of-network provider is treating you at an in-network hospital or ambulatory surgical center without getting your consent to receive a higher bill.
Ask me if you’re not sure if these protections apply to you. If you sign this form, be aware that you may pay more because:
You’re giving up your legal protections from higher bills.
You may owe the full costs billed for the services you get.
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.
Before deciding whether to sign this form, you can contact your health plan to find an in-network provider. If there isn’t one, you can also ask your health plan if they can work out an agreement with me (or another provider) to lower your costs. See the next page for your cost estimate.
Estimate of what you could pay if you give up your protections
The total cost estimate of what you may be asked to pay is listed at the bottom of this documentation..
Next steps:
Review your detailed estimate. See the next pages for a cost estimate for mental health services.
Call your health plan. Your plan may have better information about how much you’ll be asked to pay. You also can ask about what’s covered under your plan and your provider options.
Questions about this notice and estimate? Contact me directly at susan@susanbarkertherapy.com or 208-314-0555.
Questions about your rights? The federal phone number for information and complaints is: 1-800-985-3059.
Prior authorization or other care management limitations
Except in an emergency, your health plan may require prior authorization (or other limitations) for certain services. This means you may need your plan’s approval that it will cover services before you can get them. If your plan requires prior authorization, ask them what information they need for you to get coverage.
More information about your rights and protections
Visit www.cms.gov/nosurprises/consumers for more information about your rights under federal law.
By signing, I understand that I’m giving up my federal consumer protections and may have to pay more for out-of-network care.
With my signature, I’m agreeing to get mental health services from Counseling208, LLC DBA Susan Barker Therapy, provider Susan Barker, LPC
With my signature, I acknowledge that I’m consenting of my own free will and I’m not being coerced or pressured. I also acknowledge that:
I’m giving up some consumer billing protections under federal law.
I may have to pay the full charges for these services, or have to pay additional out-of-network cost-sharing under my health plan.
I was given a written notice (this form) that explained my provider isn’t in my health plan’s network, described the estimated cost of this service, and disclosed 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 of the 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 in writing before getting services.
IMPORTANT: You don’t have to sign this form. If you don’t sign, I may not be able to treat you, but you can choose to get care from a provider that’s in your health plan’s network.
The amount below is only an estimate; it isn’t an offer or contract for services. This estimate shows the full estimated costs of mental health services. 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 if your plan will pay any portion of these costs, and how much you may have to pay out-of-pocket.
IMPORTANT: I cannot list a diagnosis for you until we have met and I have completed a diagnostic assessment. As soon as a diagnosis is identified, I will inform you. Your diagnosis will not impact the amount you are charged for mental health services.
Examples of cost based on the number of sessions the average client attends.
Cost for individual psychotherapy, 50-minutes, weekly with intake assessment and 6 or 12 months of sessions, and with additional 30 minutes added (not always reimbursable with insurance):