DR AURA No Surprises Act Notification-Cash Pts Only

Dear Patient:

In compliance with the No Surprises Act that went into effect January 1, 2022, all healthcare providers including psychiatrists and therapists are required to notify patients of their federal rights and protections against “surprise billing.” The purpose of the Act and of this document is to protect you from unexpected medical bills.

This Act requires that I notify you of your federally protected rights to receive a notification when services are rendered by an out-of-network psychiatrist (as I often am), if you are uninsured, or if you elect not to use your insurance.

In case any of these situations apply to you, I am required to provide you with a “Good Faith Estimate” of the cost of services to you. Doing so is particularly challenging in mental health care because it is difficult to predict the length of treatment, and because patients have a right to decide how long they want to participate. Therefore, I describe below the fees that typically apply for the types of services I offer, including for your condition. Going forward, we can collaborate on a regular basis to determine how many sessions you may need.

My current fee schedule:

60 minutes/ Initial psychological evaluation: $225.00
Brief Phone Consultation. Up to 10 minutes without charge for established patients only. For questions or concerns that require speaking to me between scheduled appointments that do not require a full visit. Between 11-15 Minutes. $45.00.
As I perform a range of psychological testing modalities, each varying in length and complexity, there is variability in the fees of psychological testing evaluations. Please contact our office directly to get an estimated quote tailored to your circumstances.
These fees apply to all DSM diagnostic codes of the American Psychiatric Association.
I use diagnostic codes that are clinically accurate, but these do not guarantee reimbursement.

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Most often:

Therapy is done once or twice weekly, but sometimes more or less often.
Therapy continues for six months, one year, or several years, but short-term, brief therapy for intercurrent issues is also common. As noted above, because of this variability, please ask me about what can be expected in your case.
Psychological Testing has variability due to the type, please ask me what can be expected in your case.

Required Disclaimers:

Should you have additional questions about your rights under this act, you can contact any of the following:The U.S. Centers for Medicare & Medicaid Services (CMS) at 1- 800-MEDICARE (1-800-633-4227) or visit <https.//www.cms.gov/nosurprises> for more information about your rights under federal law. The Illinois Department of Insurance, Office of Consumer Health Insurance at (877) 527-9431.
If you are billed for more than this Good Faith Estimate you have the right to dispute the bill. You may 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 dispute process within 120 days (about 4 months) 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 healthcare provider, you will have to pay the higher amount.

Sincerely,

Dr. Aura Rubin, PhD.

Responsible Legal part name (Patient if 18+, or legal guardian/parent)

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Signature

Date

Aura Villamil- Rubin, PhD.