You will receive a link with access to our private portal, where you can sign and complete all of our intake paperwork securely.
If you would like me to coordinate care with another provider (for example, your psychiatrist, primary care physician, etc.), complete this form to authorize release of psychotherapy information:
Note: To download Adobe Acrobat Reader for free, Click here.
NO SURPRISE ACT 2022:
Mindful Directions Counseling Center may be out of network with your particular insurance. Please reach out to one of our clinicians to discuss Financial responsibility. We can provide you with a Good Faith Estimate to inform you of approximate cost of service prior to your first appointment.
The Good Faith Estimate is only an estimate; it isn’t an offer or contract for services. It doesn’t include any information about what your health plan may cover. This means that the final cost of services may be different than this estimate.
Contact your health plan to find out how much, if any, your plan will pay and how much you may have to pay. Please do not hesitate to reach out to us for any clarification on your rights within this new Act for 2022.
More information about your rights and protections
Visit https://www.cms.gov/nosurprises for more information about your rights under federal law.
Standard Notice and Consent Documents Under the No Surprises Act
(For use by nonparticipating providers and nonparticipating emergency facilities beginning January 1, 2022)
Instructions
The Department of Health and Human Services (HHS) developed standard notice and consent documents under section 2799B-2(d) of the Public Health Service Act (PHS Act). These documents are for use when providing items and services to participants, beneficiaries, enrollees, or covered individuals in group health plans or group or individual health insurance coverage, including Federal Employees Health Benefits (FEHB) plans by either:
• A nonparticipating provider or nonparticipating emergency facility when furnishing certain post-stabilization services, or
• A nonparticipating provider (or facility on behalf of the provider) when furnishing non emergency services (other than ancillary services) at certain participating health care facilities.
These documents provide the form and manner of the notice and consent documents specified by the Secretary of HHS under 45 CFR 149.410 and 149.420. HHS considers use of these documents in accordance with these instructions to be good faith compliance with the notice and consent requirements of section 2799B-2(d) of the PHS Act, provided that all other requirements are met. To the extent a state develops notice and consent documents that meet the statutory and regulatory requirements under section 2799B-2(d) of the PHS Act and 45 CFR 149.410 and 149.420, the state-developed documents will meet the Secretary’s specifications regarding the form and manner of the notice and consent documents.
These documents may not be modified by providers or facilities, except as indicated in brackets or as may be necessary to reflect applicable state law. To use these documents properly, the nonparticipating provider or facilitymust fill in any blanks that appear in brackets with the appropriate information. Providers and facilities must fill out the notice and consent documents completely and delete the bracketed italicized text before presenting the documents to patients.
In particular, providers and facilities must fill in the blanks in the “Estimate of what you may pay” section and the “More details about your estimate” section before presenting the documents to patients.
The standard notice and consent documents must be given physically separate from and not attached to or incorporated into any other documents. The documents must not be hidden or included among other forms, and a representative of the provider or facility must be physically present or available by phone to explain the documents and estimatesto the individual, and answer any questions, as necessary. The documents must meet applicable language access requirements, as specified in 45 CFR 149.420. The provider or facility is responsible for
translating these documents or providing a qualified interpreter, as applicable, when necessary to meet those requirements. The standard notice must be provided on paper, or, when feasible, electronically, ifselected by the individual. The individual must be provided with a copy of the signed consent documentin-person, by mail or via email, as selected by the individual.
If an individual makes an appointment for the relevant items orservices at least 72 hours before the date that the items and services are to be furnished, these notice and consent documents must be provided to the individual, orthe individual’s authorized representative, at least 72 hours before the date that the items and services are to be furnished. If the individual makes an appointment for the relevantitems or services within 72 hours of the date the items and services are to be furnished, these notice and consent documents must be provided to the individual, orthe individual’s authorized representative, on the day the appointment is scheduled. In a situation where an individual is provided the notice and consent documents on the day the items or services are to be furnished, including for post-stabilization services, the documents must be provided no laterthan 3 hours prior to furnishing the relevantitems or services.
NOTE: The information provided in these instructions is intended to be only a general informal summary of technical legalstandards. It is not intended to take the place of the statutes, regulations, or formal policy guidance upon which it is based. Refer to the applicable statutes, regulations, and other interpretive materials for complete and current information.
Do not include these instructions with the standard notice and consent documents given to patients.
Paperwork Reduction Act Statement
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a validOffice of Management and Budget (OMB) control number. The valid OMB control number for this information collection is 0938-1401. The time required to complete this information collection is estimated to average 1.3 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestionsforimproving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26- 05, Baltimore, Maryland 21244-1850.
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Surprise Billing Protection Form
The purpose of this document is to let you know about your protections from unexpected medical bills. It also asks whether you would like to give up those protections and pay more for out-of-network care.
IMPORTANT: You aren’trequired to sign this formand shouldn’tsign itif you didn’t have a choice of health care providerwhen you received 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 this provider or facility isn’tin your health plan’s network. This means the provider or facility doesn’t have an agreement with your plan.
Getting care from this provider or facility could cost you more.
If your plan coversthe item or service you’re getting, federal law protects you from higher bills: • When you get emergency care from out-of-network providers and facilities, or • When an out-of-network provider treats you at an in-network hospital or ambulatory surgical center without your knowledge or consent.
Ask your health care provider or patient advocate if you need help knowing if these protections apply to you.
If you sign this form, you may pay more because:
• You are giving up your protections under the law.
• You may owe the full costs billed for items and servicesreceived.
• Your health plan might not count any of the amount you pay towards your deductible and out of-pocket limit. Contact your health plan for more information.
You shouldn’tsign this form if you didn’t have a choice of providers when receiving care. For example, if a doctor was assigned to you with no opportunity to make a change.
Before deciding whether to sign this form, you can contact your health plan to find an in-network provider or facility. If there isn’t one, your health plan might work out an agreement with this provider or facility, or another one.