THE INITIAL MISSION OF THE NO SURPRISES ACT EFFECTTVE JANUARY 1, 2022 IS TO PROVIDE GOOD FAITH ESTIMATES TO PROTECT CLIENTS FROM SURPRISES FOR CLIENTS WITHOUT INSURANCE PLAN COVERAGE OR CLIENTS WHO WILL NOT REQUEST REIMBURSEMENT FROM THEIR HEALTH CARE PLANS

The No Surprises Act took effect on January l, 2022. This law requires health care professionals including mental health providers and physicians of all medical disciplines to provide "Good Faith Estimates" of charges for health care services to clients who do not have insurance or health care coverage or who are not intending to use their health care insurance to pay their providers. These clients plan to pay for health care with "out of pocket" funds. This Federal law requires providers to give new clients and even clients already receiving their services under these circumstances a Good Faith Estimate for services, when possible, prior to the first service date or upon request, even if an appointment has not been made. This procedure assures that clients will be aware of estimated expenses for the services they request. The goal of this act is protection of clients from unexpected or surprising charges.

All health care providers including psychologists like myself are requested to provide clients estimates for the requested services they intend to pay "out of pocket." New clients will be informed of the Good Faith Estimate orally and in writing prior to our first meeting. I will provide the Good Faith Estimate in writing by email or mail a hard copy by USPS. I will ask clients to sign 2 copies so that they will have one copy to keep for their records and I will have one copy for my records. This document will confirm that clients are informed and protected by the No Surprises Act.

The No Surprises Act permits that if charges are $400 or more beyond the estimated agreed upon charges listed and approved in the Good Faith Estimate, the client has the right to bring the charges in excess of $400 to the attention of the Provider for discussion; request an updated bill to match the original Good Faith Estimate; request a re-negotiated bill consistent with the initial agreement made; and/or request financial assistance by means of a courtesy consideration. If need be, the client may start a dispute resolution process by going to www.cms.gov/nosurprises or phone Health and Human Services at (800) 368-1019.

At any time, if services are begun, clients are encouraged to speak with me about any questions they may have including their treatment plan and/or the information provided to them in this Good Faith Estimate.

Clients will receive from me, as soon as possible when services are being discussed and scheduled, a copy of this summary of the No Surprises Act and a personal letter containing the Good Faith Agreement, which will estimate charges for the designated period of treatment to which we agree. This period of time can and may be modified as treatment proceeds. If so, at that time a new Good Faith Estimate will be calculated. When they receive their Good Faith Estimate, I will ask them to read it thoroughly, sign the two copies I provide, keep one copy of the letter for their records and return one signed copy to me.

Please print and sign the 2 copies of this notice confirming you are informed of the No Surprises Act. Keep one copy for your records and return one signed copy to me.

Thank you.
Marlene N Kasman, Ph.D