SURPRISE BILLING PROTECTION

Stony Brook Counseling Center

7491 W. Oakland Park Blvd. Ste 308

Ft. Lauderdale, FL 33319

954-746-5667

Surprise Billing Protection Form & Good Faith Estimate

This document describes your protections against unexpected medical bills. It also asks if you’d 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 before scheduling 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 picture and/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 and is considered out-of-network. This means the provider or facility doesn’t have an agreement with your plan to provide services. Getting care from this provider or facility will likely cost you more. If your plan covers the item or service you’re getting, federal law protects you from higher bills

when:

 • You’re getting emergency care from an out-of-network provider or facility, or

• An out-of-network provider is treating you at an in-network hospital or ambulatory surgical center without getting your consent to receive a higher bill.

Ask your health care provider or patient advocate if you’re not sure if these protections apply to you.

If you sign this form, be aware that you may pay more because:

• You’re giving up your legal protections from higher bills.

• You may owe the full costs billed for the items and services you get.

• 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.

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, you can also ask your health plan if they can work out an agreement with this provider or facility (or another one) to lower your costs. You will receive a customized Good Faith Estimate for your cost estimate.

Disclaimer

This Good Faith Estimate shows the costs of items and services that are reasonably expected for your health care needs for an item or service. The estimate is based on information known at the time the estimate was created, and does not include any unknown or unexpected costs that may arise during treatment.

If you are billed for more than this Good Faith Estimate, you have the right to dispute the bill. Throughout your treatment, the provider may recommend additional items or services as part of your treatment that are not reflected in this estimate. These would need to be scheduled separately with your consent and the understanding that any additional service costs are in addition to the Good Faith Estimate.

If your needs change during treatment, your provider should supply a new, updated Good Faith Estimate to reflect the changes to treatment, and the accompanying cost changes. You may contact the health care provider or facility listed to let them know the billed charges are higher than the Good Faith Estimate. You can ask them to update the bill to match the Good Faith Estimate, ask to negotiate the bill, or ask if there is financial assistance available.

The Good Faith Estimate is not a contract between provider and client and does not obligate or require the client to obtain any of the listed services from the provider.

You may also 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 calendar 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 health care provider or facility, you will have to pay the higher amount.

To learn more and get a form to start the process, go to www.cms.gov/nosurprises or call HHS at (800) 985-3059. For questions or more information about your right to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprises or call (800) 985-3059. Keep a copy of this Good Faith Estimate in a safe place or take pictures of it. You may need it if you are billed a higher amount.