Telegraph Psychology Collective / North Berkeley Counseling Collective: Good Faith Estimate notice for self-pay clients, under the federal No Surprises Act
You have the right to receive a “Good Faith Estimate” explaining the expected cost of your health care.
Under the federal No Surprises Act, health care providers generally must provide a Good Faith Estimate to individuals who are not enrolled in a health plan or other health care coverage, or who are enrolled but do not intend to have a claim submitted to their health plan for the services at issue.
If these requirements apply to you, Telegraph Psychology Collective, PC, doing business as North Berkeley Counseling Collective (“the Practice”), will provide you with a written Good Faith Estimate when your services are scheduled sufficiently in advance or when you request an estimate. You may request a Good Faith Estimate before scheduling services.
Your Good Faith Estimate will describe the services reasonably expected to be provided and the anticipated charges based on the information known when the estimate is prepared. Because psychotherapy is individualized, the length, frequency, and total duration of treatment cannot always be predicted in advance. An estimate for recurring psychotherapy may therefore be based on an anticipated frequency and period of treatment. Your treatment needs, preferences, schedule, or recommended level of care may change over time.
A Good Faith Estimate is not a contract and does not require you to obtain the services listed in the estimate. It does not prevent you and your treating clinician from agreeing to different or additional services. If the expected services or charges materially change, the Practice may provide an updated Good Faith Estimate.
You may incur charges not included in an earlier estimate if you request or receive additional services, including longer sessions, family or collateral sessions, reports, record preparation, consultations, court or legal services, psychological testing, missed-appointment fees, or other separately agreed-upon services. When reasonably possible, the Practice will inform you of additional charges before providing the service.
If you receive a bill from the Practice that is at least $400 more than the total expected charges listed in the applicable Good Faith Estimate, you may be eligible to dispute the bill through the federal patient-provider dispute-resolution process.
Please retain a copy of every Good Faith Estimate you receive.
For questions about your estimate or to request a Good Faith Estimate, contact:
Telegraph Psychology Collective, PC
DBA North Berkeley Counseling Collective
Telephone: 510-224-5591
Email: hello@telegraphpsychology.com
For additional information about Good Faith Estimates and your rights under the No Surprises Act, visit www.cms.gov/nosurprises.
Acknowledgment of Receipt
If you are a self-pay client, you will be asked to acknowledge that you received this notice when you begin services. Acknowledging receipt does not waive any rights you may have under federal or state law.