Good Faith Estimate for Health Care Items and Services Under the No Surprises Act

This disclosure is part of and incorporated into Boston Somatic Therapy, Inc’s general services agreement and its intake documents. The federal No Surprises Act requires Boston Somatic Therapy, Inc to disclose its fees and the actions it will take and will not take relating to billing and the coordination of benefits with your insurance. Boston Somatic Therapy, Inc currently operates under the following fee schedule, and schedules only at the patients request for service:

Individual Psychotherapy: $250

Throughout the course of your therapeutic relationship with Boston Somatic Therapy, Inc, you may receive services that are different from your initial plan. This disclosure ensures that you understand and agree that Boston Somatic Therapy, Inc’s fees are due whether or not your insurance covers a service, whether or not your insurance covers a service in an amount different from what was initially believed to be covered, or whether or not a service is defined, categorized, or billed in a manner that is different from a manner accepted by your insurance company. By signing on to treatment, you will sign this form in your intake paperwork. By doing so, you acknowledged that Boston Somatic Therapy, Inc will not be an arbiter of disagreements between you and your insurance company. Boston Somatic Therapy, Inc will not be held responsible for any unexpected or surprise actions taken by your insurance company, and you are responsible for the services you receive from Boston Somatic Therapy, Inc whether or not your insurance company pays for or covers such services.

At your request, a Good Faith Estimate can be provided for the estimated charges over the course of 12 months. It is only valid for 12 months. You may estimate this cost on your own by multiplying your specific rate above (either individual or relationship psychotherapy) by the terms decided upon in our work together (weekly, bi-weekly, monthly), please account for at least 4 weeks off, although this may vary. If you have health insurance, and the services you are seeking are covered by your health care plan, you may be able to get the items or services described in this notice from providers who are in-network with your health plan. 

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.

The Good Faith Estimate does not include any unknown or unexpected costs that may arise during treatment. You could be charged more if complications or special circumstances occur. If this happens, and your bill is $400 or more for any provider or facility than your Good Faith Estimate for that provider or facility, federal law allows you to dispute the bill.

The Good Faith Estimate is not a contract and does not require the uninsured (or self-pay) individual to obtain the items or services from any of the providers or facilities identified in the Good Faith Estimate.

For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises.