As an out of network provider, I do not bill insurance companies directly. Depending on your current health insurance provider you may be eligible for out of network benefits. At your request I can provide a statement of service for you to submit to your insurance company for possible reimbursement. If you are unsure about your coverage, please contact your provider to verify how your plan compensates for psychotherapy services.

Here are some questions to ask your insurance carrier to understand your coverage:

• What is my coverage for outpatient mental health services?

• What is my yearly deductible, and has it been met?

• What is the reimbursement rate for an out-of-network provider?

• How many therapy sessions are covered in a calendar year?

• Are there any limits to my coverage?

• What is the reimbursement rate for CPT code 90837 (Individual Therapy).

Payment will be due at the time of service, at the beginning of the session. Acceptable methods of payment are all major credit cards, as well as HSA/HFA cards.

I understand that things come up, so you can cancel or reschedule your appointment with at least 24 business hours (M-F) notice. If it’s less than 24 business hours notice, you will be charged for the full rate of the appointment with the credit card you have placed on file at the onset of treatment. If cancellations/no shows continue to occur, we will process this together as this may indicate some resistance to the therapeutic work. Excessive cancellations/no shows (3 or more) will result in termination of services. In order for therapy to be effective, consistent attendance is necessary.

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

Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the expected charges for medical services, including psychotherapy services.

You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency healthcare services, including psychotherapy services.

You can ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule a 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.

For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises or call 800-985-3059.