NSA Forms

In compliance with the No Surprise Act (NSA) that goes into effect in 2022, all healthcare providers are required to notify clients of their Federal rights and protections against “surprise billing“. This act requires that I notify you of your federally protected rights to receive a notification when services are rendered by an out of network provider, if a client is uninsured, or if a client elects not to use their insurance. I am also required to post on my website the federally generated standard notice and no surprise billing notice. These documents are given below that will allow you to download your own copies.

Additionally, I am required to provide you with a Good Faith Estimate (GFE) of cost of services. It is difficult to determine the true length of treatment for mental health care, and each client has a right to decide how long they would like to participate in mental health care. If you are my client, we have discussed the NSA Notices and your Good Faith Estimate already in our session and I have provided those in writing through the mail and/or encrypted email to you. It is a requirement that I have each client sign an acknowledgment of our discussion and your receipt of these documents to begin/resume treatment.

To do this, please go to the ”NSA Good Faith Estimate Client Signature” page below and complete and submit it through the website before your next appointment. If you have any questions, please don’t hesitate to contact me.

NSA Standard Notice

NSA Balance Billing Notice

NSA Good Faith Estimate Client Signature Page