Good Faith Estimate

Currently, I am an in network provider with the following insurance plans: BC/BS plans, CareFirst plans, Cigna/Evernorth plans and Johns Hopkins EHP plans. I strive to provide you with accurate information about the amount of any copayments/coinsurance payments and/or deductible payments that you will owe prior to your first appointment with me.

As of January 1st, 2022, the Centers for Medicare and Medicaid Services (CMS) instigated a new Federal rule (the “No Surprises Act”) to protect patients from unexpected medical bills and to increase transparency between health care clinicians and patients.

This rule requires all medical and mental health clinicians (including LCSWs) to give a “good faith estimate” (GFE) to patients estimating the cost of services and how long services may last.  You can ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule a service.

I am also required to inform you that if I am an “out-of-network” provider for your insurance plan, I do not submit claims to insurance and do not get paid by insurers.

If I am an “out of network” provider with your plan, I may ask you to review, complete and sign an additional form. By signing this form, you acknowledge the following:

·        You have made a choice to not use your health insurance and seek a provider who may be in-network with your plan.

·        You may or may not pay more for my services then your health insurance plan pays.

·        You will pay me the full cost for each service I provide, as we have discussed.

Upon request, I can provide you what is known as a Superbill (receipt), which you can submit to your health insurance company. However, please be aware that your plan might not reimburse you, the payment may be of lesser amount than what you have paid me and/or they might not count any of the amount you pay towards your deductible and out-of-pocket limit. You have the right to receive a “Good Faith Estimate” explaining how much your medical and mental health care will cost.

You can dispute a medical bill if your final charges are at least $400 higher than your good faith estimate, and you file your dispute claim within 120 days of the date on your bill. Make sure to save a copy or picture of your Good Faith Estimate.

For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises or call the Help Desk at 1-800-985-3059 for more information. TTY users can call 1-800-985-3059.