NO SURPRISE BILLING ACT INFORMATION

Good Faith Estimate

You have the right to receive a Good Faith Estimate of Expected Charges under the No Surprises Act. If you are choosing to use out-of-network benefits, this information is included in an introductory email from Introspect Mental Health. If you would like to receive your Good Faith Estimate in paper form, please contact our main line and or let your provider know.

You have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost

Under the law, healthcare providers need to give patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services.

You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees.

Make sure your healthcare provider gives you a Good Faith Estimate in writing at least 1 business day before your medical service or item.

You can also ask your healthcare provider, and any other provider you choose, for a Good Faith Estimate before you schedule an item or service.

If you receive a bill that is at least $400 more than your Good Faith

Estimate, you can dispute the bill.

Make sure to save a copy or picture of your Good Faith Estimate.

GENERAL FEES FOR SERVICES

Code 90791: Diagnostic Assessment $350.00

Code 90832: 30 Minute Session $200.00

Code 90834: 45 Minute session $250.00

Code 90837: 53 Minute Session $275.00

Code 90847: Family Session $275.00

Late Cancel- Less than 24 hour notice/ No Call/ No Show: $100.00

For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises or call our main line at (763) 465-6700.