As required by CMS and Federal Legislation, effective January 1, 2022 (the “No Surprises Act”) the
Practice is required to provide you with a good faith estimate for services. The Practice’s office policies
outline most of the requirements of this legislation, but this separate document will include the
information in a way that complies with this legislation.
The purpose of this document is to let you know about your protection from unexpected medical bills. It
also asks whether you would like to give up those protections and pay more for out-of-pocket network
Important: You aren’t required to sign this form and shouldn’t if you didn’t have a choice of health care
providers 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, please contact the
practice. Please retain a copy for your records.
You are getting this notice because this provider or facility isn’t in your health plan’s network. This
means the provider and facility do not have an agreement with your plan. Getting care from this provider
or facility could cost you more.
If your plan covers the items(s) or service(s) you are getting, Federal law protects you from higher bills:
1. When you get emergency care from out-of-network providers and facilities
2. When an out-of-network provider treats you at an in-network hospital or ambulatory surgical center without your knowledge or consent.
Ask your healthcare provider or patient advocate if you need help knowing if these protections apply to
If you sign this form, you may pay more because:
1. You are giving up your protections under the law.
2. You may owe the full costs billed for items and services received.
3. Your health care 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 practice. If there isn’t one, your health plan might work out an agreement with another
provider or practice.
Please see below for your cost estimate.
Estimate of What You Could Pay: $9,100
Patient Name: ______________
Out-of-Network Facility Name: HP Psychotherapy, LLC
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.
Your provider has the right to refer you to another appropriate provider if treatment frequency cannot be
agreed upon. Please see the breakdown of possible fees below.
1. Review your detailed estimate. See below for a cost estimate for each item or service.
2. Call your health plan. Your plan may have better information about how much of these services are reimbursable.
3. Questions about this notice and estimate? Call 678-561-3399 or e-mail: email@example.com
4. You have the right to dispute the charges if they are $400 over the estimate. Please note: no-show and late cancellation fees, as well are emergency sessions are not included in the estimate. You understand that if you are in clinical need of emergency services and/or do not comply with the practice’s cancellation and no-show policy, the estimate will be more. If you choose to use the dispute resolution process within the U.S. Department of Health and Human Services (HHS), you must start the process within 120 calendar days 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 the Good Faith Estimate. If the agency disagrees with you and agrees with the health care provider or facility, you will have to pay the higher amount. To learn more information and get a form to start the process go to: www.cms.gov/nosurprises.
Prior Authorizations 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 receive them. If prior authorization is required, please ask your health plan about what
information is necessary to get coverage.
More Information About Your Rights and Protections:
https://www.cms.gov/files/document/model-disclosure-notice-patient-protections-against-surprise-billingproviders-facilities-health.pdf for more information about your rights under Federal law.
By signing this form, I give up my Federal consumer protections and agree I might pay more for
With my signature, I am saying that I agree to get the items or services from the practice, HP Psychotherapy, LLC, and Hannah Paull, PsyD, NPI Number: 1033721113.
With my signature, I acknowledge that I am consenting of my own free will and am not being
coerced or pressured. I also understand the following:
1. I am giving up some consumer billing protections under Federal law.
2. I may get a bill for the full charges for these items and service or have to pay out-of-network cost-sharing under my health plan.
3. I was given written notice 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.
4. I received the notice either on paper or electronically.
5. I fully and completely understand that some or all amounts I pay might not count towards my health plan’s deductible or out-of-pocket limit.
6. 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. However, if you don’t sign this form, this provider of
facility might not treat you.
Employer Identification Number: 85-4541201
NPI Number: 1033721113
Patient’s Name: ______________
Patient’s DOB: ______________
Current Diagnostic Code(s): ______________
*For new patients, a diagnosis will be provided upon intake and they will receive an updated document
with a diagnostic code.
Out-Of-Network Provider and Facility Name: Hannah Paull, PsyD / HP Psychotherapy, LLC
The amount below is only an estimate; it is not an offer or contract for services. This estimate shows the
full estimated cost 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.
Patient Name: _______
At this time, all services are conducted virtually. Additional modifiers that you will see on your superbill
may include “GT” or “95” to represent telehealth services. The place of service (in-office “10” vs. telehealth “02”) is not delineated above since the charges are the same.
Patients are required to pay for services at the time that they are provided.
Total Cost: $175 for every session billed for CPT code 90837. If a patient were to attend weekly psychotherapy with 0 cancellations over the course of a year, the cost would be estimated at $9,100 annually (if there are no cancellations, holidays, vacations or missed appointments). The cost of this estimate of out-of-pocket costs would be if a patient paid out-of-pocket without any insurance coverage or reimbursement based on out-of-network benefits. This cost does not reflect any no-show or late cancellation fees.
Total Estimated Cost: The total estimated cost cannot be pre-determined as every patient is different,
and their treatment needs may vary over the course of the year. As such, we provide you with the above
estimate reflecting weekly, 50 minutes sessions for 52 weeks (1 year, every week). Please speak to your
provider and review your treatment plan to determine the recommended frequency of services and specific services that will be provided.
1. There may be additional items or services that are recommended as part of the treatment plan that will be scheduled separately and are not reflected on this Good Faith Estimate.
2. The information provided in this Good Faith Estimate is only an estimate and the actual items, services, or charges may differ from the Good Faith Estimate in that the Practice cannot determine the exact number of sessions/services a patient will receive during the course of treatment.
3. Treatment plans are reviewed approximately every 90 days and the frequency of treatment is also reviewed at that time.
4. Patients will be provided with a Good Faith Estimate at the start of each year, or additionally upon their request.
5. The information here does not require any private pay patient to obtain psychotherapy services or other services from us. It simply provides informed consent to the patient should they choose to with the Practice, of estimated costs.
6. There is no guarantee that insurance will cover any part or all of the charges billed. Ultimately, it is up to the insured individual or their parent/guardian to determine if the services are covered by their insurance company, given that providers and the practice are out-of-network.