THE NO SURPRISES ACT STANDARD NOTICE AND CONSENT SUMMARY
(OMB Control Number: 0938-1401) SURPRISE BILLING PROTECTION
This federal law protects people with health insurance from unexpected bills sometimes called “balance billing.”
Queering Therapy is not in network with your insurance plan.
Contact your health plan for more info. Only your plan can confirm what, if any, reimbursement they will provide to you.
You will never receive a surprise bill from Queering Therapy.
You will agree to your session fees in advance of any session. You will be notified in advance of any rate changes. Session fees are due on the date of session, so you will not receive unexpected bills.
You will receive a personalized NO SURPRISES ACT FORM as part of your intake paperwork, which will include your GOOD FAITH ESTIMATE TABLE OF SERVICES AND FEES.
You may read your personalized NO SURPRISES ACT FORM by logging into your private portal, or by requesting a copy from your therapist.
Questions about your insurance coverage?
Contact your insurance company directly to get the specific details of your coverage.
Questions about what this means for you?
Contact: Beverly Ellison, LCSW, CST at: Info@QueeringTherapy.com or text/call: 415.969.6886.
Questions about your rights?
Contact: The Board of Behavioral Sciences at 916.574.7830
or send mail to: The Board of Behavioral Sciences 1625 N Market Blvd S-200, Sacramento, CA 95834.
or visit: www.cms.gov/nosurprises.