Good Faith Estimates

under the

No Surprises Act

NO SURPRISES ACT BILLING AND INSURANCE DISCLOSURE

This disclosure is part of and incorporated into Well Watered Roots, LLC’s general services agreement, its exhibits, and its intake documents.  The federal No Surprises Act requires Well Watered Roots, LLC 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.  Well Watered Roots, LLC currently operates under the following fee schedule, and schedules only at the patients request for service:

Individual Psychotherapy $200

Relationship Psychotherapy $250

Throughout the course of your therapeutic relationship with Well Watered Roots, LLC, you may receive services that are different from your initial plan, which may or may not be covered by your insurance company depending on changes in our billing practices, changes in your insurance coverage, or other factors.  This disclosure ensures that you understand and agree that Well Watered Roots, LLC’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 treatmet, you will sign this form in your intake paperwork. By doing so, you acknowledged that Well Watered Roots, LLC will not be an arbiter of disagreements between you and your insurance company.  Well Watered Roots, LLC 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 Well Watered Roots, LLC 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 varies.  Please keep in mind that you, as the patient, schedule your appointments, and Well Watered Roots, LLC, takes payment before each session occurs.  It is Well Watered Roots, LLC’s policy to not carry balances, therefore no surprise fees will be charged without your knowledge.  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

If Well Watered Roots, LLC provides a Good Faith Estimate, at your request, and you are billed for more than the Good Faith Estimate, you have the right to dispute the bill.  The Good Faith Estimate is just that: An estimate.