Important Info

Important Info

No Surprises Act Disclosure

Clients may choose to pay out-of-pocket for services for a variety of reasons. This form is notification of a client choosing to pay out-of-pocket for services under one of the following circumstances:

  • Client currently does not have an insurance plan and wishes to pay for services out-of-pocket.
  • Client currently does have an insurance plan that provider is out-of-network with and wishes to pay for services out-of-pocket.
  • Client currently does have an insurance plan that provider is in-network with but wishes to forgo insurance claim submissions and pay for services out-of-pocket.

Patient Rights

In accordance with Title I of Division BB of the Consolidated Appropriations Act, 2021 (CAA) amended title XXVII of the Public Health Services Act (PHS), Part E, this disclosure of patient protections against surprise bills ensures that consumers know their rights and ability to dispute. For consumers who get coverage through their employer (including a federal, state, or local government), through the Health Insurance Marketplace® or directly through an individual health plan, beginning January 2022, these rules will:

  • Ban surprise billing for emergency services. Emergency services, even if they’re provided out-of-network, must be covered at an in-network rate without requiring prior authorization.
  • Ban balance billing and out-of-network cost-sharing (like out-of-network co-insurance or copayments) for emergency and certain non-emergency services. In these situations, the consumer’s cost for the service cannot be higher than if these services were provided by an in-network provider, and any coinsurance or deductible must be based on in-network provider rates.
  • Ban out-of-network charges and balance billing for ancillary care (like an anesthesiologist or assistant surgeon) by out-of-network providers at an in-network facility.
  • Ban certain other out-of-network charges and balance billing without advance notice. Health care providers and facilities must provide consumers with a plain-language consumer notice explaining that patient consent is required to get care on an out-of-network basis before that provider can bill the consumer. For consumers who don’t have insurance, these rules make sure they’ll know how much their health care will cost before they get it and might help them if they get a bill that’s larger than expected.

Good Faith Estimate of Services

In accordance with the “No Surprises Act”, Section 2799B-6 of the Public Health Service Act, set to go into effect 01/01/2022, healthcare providers are required to provide a “good faith” estimate of expected charges for services to individuals not enrolled in a plan or coverage or a federal health program, both orally and in writing. This paperwork serves as an in writing “good faith” estimate for services rendered.

As part of this paperwork, you will also receive a master list of most potential CPT codes that could prospectively be billed and their full pricing so you will reasonably know the absolute most you could be paying for any given service. Given the nature of therapy services, typically exact estimates are difficult to predict due to not knowing severity of symptoms, recommended frequency of services, length of time of services, and any other variables.


This “good faith” estimate shows that costs of services that are reasonably expected for your healthcare needs. This estimate is based on the information known at the time the estimate was created. The estimate does not include any unknown or unexpected costs that may arise during treatment. You could be charged more if complications or special circumstances occur. If this happens, federal law allows you to dispute the bill. If you are billed for significantly more than this “good faith” estimate, you have the right to dispute the bill. You can contact us and notify that the charges are higher than the “good faith” estimate and ask us to update the bill or the estimate. You can also start a dispute resolution process with the U.S. Department of Health and Human Services (HHS). If you choose to use the dispute resolution process, you must start the process within 120 calendar days of the date on the original bill. There is a $25 fee to use the dispute process. If the agency reviewing your dispute agrees with you, you will have to pay the price on this “good faith” estimate. If the agency disagrees with you and agrees with the provider, you will have to pay the higher amount. To learn more and get a form to start the process, go to or call 1-877-696-6775.

The landscape of mental health services is rapidly changing and expanding. We at Pruden Counseling Concepts appreciate your patience as we navigate these times together. Please feel free to contact us with any questions: 1-866-200-9849/