No Surprise Act

YOUR RIGHTS AND PROTECTIONS AGAINST SURPRISE

 MEDICAL BILLS

(OMB Control Number: 0938-1401)

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What is “balance billing” (sometimes called “surprise billing”)?

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As North Metro Psychological Services is an outpatient provider and accepts private pay only, they do not accept insurance. “Out-of-network” describes providers and facilities that haven’t signed a contract with your health plan. ​

“Surprise billing” is an unexpected balance bill. You will discuss with NMPS staff prior to beginning your treatment the cost you will pay per service type.

GOOD FAITH ESTIMATE OF SERVICES AND FEES​

The Good Faith Estimate explains your provider’s rates for each service provided. Your provider 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 possible diagnoses and/or presenting clinical concerns. The list of all fees for each service type is listed here as well as in the Informed Consent signed upon beginning treatment.

If you believe you’ve been wrongly billed, you may contact: Georgia Secretary of State at (404) 651-8600

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