Dear Client and Prospective Client,

In compliance with the No Surprises Act that went into effect on January 1, 2022, healthcare consumers who don’t have insurance or who are not using their insurance have a right to receive a Good Faith Estimate for the total expected cost of any non-emergency medical items or services. The No Surprises Act also requires Debra Kaplan Counseling to notify all healthcare consumers when services are rendered by a non-participating provider.

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 or facility in your health plan’s network, which may cost you less.
If you’d like assistance with this document, ask your provider or a patient advocate. Take a picture and/or keep a copy of this form for your records.

You’re getting this notice because Debra Kaplan Counseling isn’t in your health plan’s network and is considered out-of-network. This means Debra Kaplan Counseling doesn’t have an agreement with your plan to provide services.
Getting care from Debra Kaplan Counseling (DKC) will likely cost you more.

Additionally, DKC is required to provide you with a Good Faith Estimate of the cost of services for the duration of treatment. It is difficult to determine the exact length and scope of treatment for our work together. Attached is the best estimate based on what is most typical at DKC. Please read and sign the Good Faith Estimate which follows. This estimate is provided in an effort to be as transparent as possible about your potential financial investment in services with DKC.

You may incur fees throughout your care with DKC that are in addition to costs associated with direct services. These fees include, but are not limited to:

Late cancellation/no show fee
Medical records request
Completion of documents (Summary letters, Subpoena and Court Order of documents)
Consultation/Coordination of Care

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Good Faith Estimate

Primary Diagnosis and Diagnostic Code: To be determined; fee per service will remain the same regardless of diagnosis.

Service Code	Description	Frequency	Cost	Total	

90791	Diagnostic Intake	
1-2x	
$200 per unit	
$200-$400	

90837	Individual Therapy	Weekly for 52 weeks	$160 per session	
$8,320	

90837	Extended Individal Sessions	
Monthly for 10-12 months	
$320 per session	
$3,200- 3,840	
	
Consultation	
1-10 hours	$200 per hour	
$200 -$2,000	
	Case Consultation	
1-10x	$40.00 per 15min	
$160 - $1,600	
Total Estimate:	$12,060 -$16,160	

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information about how much you will 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? Call DKC at 520.203.1943 or email info@debrakaplancounseling.com

More information about your rights and protections: Visit https://www.cms.gov/nosurprises for more information about your rights under federal law. You can also contact the Department of Health and Human Services with questions.

My initials and signature below indicate that I give up my federal consumer protections and agree to pay more for out-of-network care. Ub addition, I agree to get the services indicated from Debra Kaplan Counseling.

With my signature, I acknowledge that I am consenting of my own free will and am not being coerced or pressured. I understand that I am giving up some consumer billing protections under federal law.

I may get 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 written notice on

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 Debra Kaplan Counseling.

I got 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 r out of pocket limit.

I can end this agreement by notifying Debra Kaplan Counseling as per the Consent Agreement terms in writing before getting services.

Client Name: Client Signature
Date:

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