You are getting this notice because this provider or facility is not in your health plan’s network. This means the provider or facility does not have an agreement with your plan.
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 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 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 should not sign this form if you did not 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 is not one, your health plan might work out an agreement with this provider or facility, or another one.
What you should do:
►Review your detailed estimate at the end of this document.
►Call your health plan if you have questions about reimbursement. Your plan may have better information about how much you will be asked to pay. You also can ask about what’s covered under your plan and your provider options.
Prior authorization or other care management limitations
[Enter either (1) specific information about prior authorization or other care management limitations that are or may be required by the individual’s health plan or coverage, and the implications of those limitations for the individual’s ability to receive coverage for those items or services, or (2) include the following general statement:
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.]
Understanding your options
You can also get the items or services described in this notice from these providers who are in-network with your health plan. Please contact your insurance company for a list of participating providers.
By signing, I give up my federal consumer protections and agree to pay more for out-of-network care.
With my signature, I am saying that I agree to receive the services from Avvy Mar, PhD, PC.
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 am giving up some consumer billing protections under federal law.
• I will receive a bill for the full charges for these items and services, which is due at the time services are rendered.
• I was given a written notice on intake explaining that my provider or facility is not in my health plan’s network, the estimated cost of services, and what I will 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 my health 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 do not have to sign this form. But if you do not sign, this provider or facility might not treat you. You can choose to get care from a provider or facility in your health plan’s network.
The amount below is only an estimate; it isn’t an offer or contract for services. While it is not possible for a psychologist to know, in advance, how many sessions may be necessary or appropriate for a given person, this form gives an estimate of potential costs associated with my services. Your total costs will be dependent on the number of sessions you attend, your individual circumstances and the frequency of services provided.
This estimate shows the full estimated costs of 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.
Contact your health plan to find out how much, if any, your plan will pay and how much you may have to pay.
Good Faith Estimate: