Good Faith Estimate

DKC Good Faith EstimateDownload

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 (DKC) to notify all healthcare consumers when services are rendered by a non-participating provider.

IMPORTANT: Getting care from (DKC) will likely cost you more than your in-network services.

Clients are not required to accept treatment if they choose a health care provider who is outside their network. You can choose to get care from a provider or facility in your health plan’s network, which may cost you less.

This information is listed because DKC isn’t in your health plan’s network and is considered out-of-network. This means DKC doesn’t have an agreement with your plan to provide services.

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. An estimate will be provided 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

Questions about this notice and estimate? Call DKC at 520.203.1943 or email in**@de*******************.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.

The aforementioned information states that a client agrees to pay more for out-of-network care. In addition, the client agrees to get the services indicated from DKC.