No Surprise Act Standard Notice & Consent Document Orchard Human Services, Inc.

Orchard Human Services, Inc. &

Dr. Darleen Claire Wodzenski, MS ESE, MA CMHC, QPPE, PhD, LPC, NCC

4813 Ridge Road Suite 111-83 Douglasville GA 30134

(770) 686-0894 Office (877) 660-8884 Fax

OrchardHumanServices.org-Website

Appointments@OrchardHumanServices.org- Email -

THE NO SURPRISES ACT

STANDARD NOTICE & CONSENT DOCUMENTS

(OMB Control Number: 0938-1401)

NOTICE: Orchard Human Services, Inc. and/or Dr. Darleen Claire Wodzenski, PhD, LPC, NCC do participate in many insurance networks and plans including Amerigroup, AETNA, Anthem, Beacon, Blue Cross/Blue Shield, Caresource, GEHA, Optum, Cigna, Evernorth, United Healthcare and others. Please verify participation with your insurance plan prior to commencing care. Let us know if you need help contacting your insurance company.

According to governmental mandate, we must provide you with this form and related information; if you have questions, feel free to ask us. We know this is confusing and are happy to go over this form and any questions you may have. Please contact Andrew or Tiffany: (770) 686-0894 or email us at Forms@OrchardHumanServices.org

Please fill in all the blanks, check boxes, and provide signatures where requested along with date and time you signed this document. If you provide your email address, a copy of the portions of the document you filled out will be emailed directly to you. When you are done, please return to Orchard's website and download the complete "No Surprises Act Standard Notice and Consent Documents" package for your records.

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't required to sign this form and shouldn't sign it if you didn't have a choice of health care provider when 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 pictureand/ or keep a copy of this form for your records.

You're getting this notice because this provider or facility isn't in your health plan's network. This means the provider or facility doesn't have an agreement with your plan.

By signing, I give up my federal consumer protections and acknowledge I might pay more for out-of-network care.

Print name of patient*

With my signature, I am saying that I agree to get the items or services from (select all that apply)*

Orchard Human Services, Inc. and StaffDr. Darleen claire Wodzenski, MS ESE, MA CMHC, QPPE, PhD, LPC, NCC and Staff

Signature of Patient or Guardian (if client is a minor)*

Print name of guardian/authorized representative who signed above

Whose signature is this (above)?*

I am the patient who signed the form; and I am an adult.I am a guardian of the patient, who is a minor.I am a guardian or legally authorized representative of the patient, who is an adult.

Date of Signature

Date

Time of Signature

Hour Minutes

AM/PM Option

Keep a copy of this form.

It contains important information about your rights and protections.

Your Email - If you would like us to email you a copy of the completed form.

example@example.com

Orchard Human Services, Inc. &

Dr. Darleen Claire Wodzenski, MS ESE, MA CMHC, QPPE, PhD, LPC, NCC

4813 Ridge Road Suite 111-83 Douglasville GA 30134

(770) 686-0894 Office (877) 660-8884 Fax

OrchardHumanServices.org- - Website

Appointments@OrchardHumanServices.org-Email

Orchard Human Services, Inc. FEDERAL TAX ID: 35-2471025

Dr. Darleen NPI # 1629410907

Orchard GROUP NPI #1609428689

More details about your estimate

Patient name

Date of Birth

Date

You MUST choose one:*

Other [Diagnosis I Received From Another Licensed Provider - provide below]Z65.9 Problem related to unspecified psychosocial circumstances

If You Selected "Other" Diagnosis Above - Please provide the diagnosis given to you by another licensed provider; otherwise, please write Z65.9 in this box.*

With my signature, I acknowledge that I am consenting of my own free will and am not being coerced or pressured. I also understand that: I'm giving up some consumer billing protections under Federal law. I may get a bill for the full charges for these items and services or have to pay out-of- network cost-sharing under my health plan. I was given a written notice on[DATE] explaining that my provider or facility isn't in my health plan's network, the estimated cost of services, and what I may owe if I agree to be treated by this provider or facility. I got the notice either on paper or electronically, consistent with my choice. I fully and completely understand that some or all amounts I pay might not count toward myhealth plan's deductible or out-of-pocket limit. I can end this agreement by notifying the provider or facility in writing before getting services.

IMPORTANT: You don't have to sign this form. But if you don't sign, this provider or facility might nottreat you.

Out-of-network provider(s) or facility name:

Orchard Human Services, Inc. and/or

Dr. Darleen Claire Wodzenski, MS ESE, MA CMHC, QPPE, PhD, LPC, NCC

The amount below is only an estimate; it isn't an offer or contract for services. This estimate shows the full estimated costs of the items or services listed. 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.

Once you have completed and submitted this form,

please download the next document on the website:

GOOD FAITH ESTIMATE - TABLE OF SERVICES AND FEES

Getting care from this provider or facility could cost you more. If your plan covers the 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 surgicalcenter 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 services received. 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't sign 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.

Estimate of what you could pay:

Out-of-network provider(s) or facility name: Orchard Human Services, Inc. and/or

Dr. Darleen Claire Wodzenski, MS ESE, MA CMHC, QPPE, PhD, LPC, NCC

Total cost estimate of what you may be asked to pay: It is your ethical right to determine your goals for treatment and how long you would like to remain in therapy unless you are pursuing mandatory treatment. Please see the breakdown of possible fees on page four. Review your detailed estimate. See page four for a cost estimate for each item or service. Call your health plan. Your plan may have better information about how much of these services are reimbursable. Questions about this notice and estimate? Call (770) 686-0894 and ask for Andrew or Tiffany

Questions about your rights? Call (770) 686-0894 and ask for Andrew or Tiffany

Prior authorization or other care management limitations Except in an emergency, your health plan may require prior authorization (or other limitations) for certain items and services. This means you may need your plan's approval that it will cover an item or service before you get them. If prior authorization is required, ask your health plan about what information is necessary to get coverage.

More information about your rights and protections

Visit https://www.cms.gov/files/document/model-disclosure-notice-patient-protections-against urprise-billing-providers-facilities-health.pdf for more information about your rights under federal law.

Client Name*

Today's Date*

Date

Fee Schedule:

CPT Code or Name; Description; Fee in US Dollars

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90791; Initial Diagnostic Evaluation; $200

90832; Psychotherapy, 16-37 minutes; $125

90834; Psychotherapy, 38-52 minutes; $150

90837; Psychotherapy ≥ 53 minutes; [This fee is the hourly rate that is also used for all prorated calculations]; $175

90853; Group Psychotherapy; $75

98966-98968; Telephone Assessment & Management; Prorated based on amount of time spent at hourly rate.

98970-98972; Online Digital Evaluation & Mgt [Responding to Email & Text Messages] Prorated based on the amount of time spent at hourly rate

Late Cancelation Fee; We Require 24-Hour Notice for Cancelation; You are Responsible for Fee of Missed Appointment.

99446; Interprofessional Consultation of medical consultative discussion and review 5-10 minutes; $75

99447; Interprofessional Consultation 11-20 minutes; $100

99448; Interprofessional Consultation 21-30 minutes; $160

99449; Interprofessional Consultation ≥ 31 minutes; $200

Production of Records; Our costs for reproducing, accessing, and delivering paper or electronic forms; $.50 Per Page

Intervention (Developmental or Educational); May include Educational Therapy (not clinical services), Educational Support, Developmental Training; $50 per session.

Court & Legal Fees; Hourly cost of records review, research, preparation, and testimony; $500

NOTE: This Good Faith Estimate explains your therapist's rate for each service provided. Your therapist will collaborate with you throughout your treatment to determine how many sessions and/or services you may need to receive the greatest benefit based on your Diagnosis(es)/presenting clinical concerns.

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Your Good Faith Estimate:

# Times ___ for 1st Service X Cost Per Service $___ = $______

# Times ___ for 2nd Service X Cost Per Service $___ = $______

# Times ___ for 3rd Service X Cost Per Service $___ = $______

# Times ___ for 4th Service X Cost Per Service $___ = $______

_______________________________________________

Add All Services Above for Estimate TOTAL = $______**

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**Please note that Place of Service [In-Office V. Telemental Health] is not delineated above as charges are same.

END OF DOCUMENT

Signature of Patient or Guardian*

Date of Signature of Patient or Guardian*

Date