Surprise Billing Protection Form

Standard Notice: “Right to Receive a Good Faith Estimate of Expected Charges” Under the No Surprises Act

The following information is being presented to you due to the new federal law called the “No Surprises Act” which went into effect 1/1/2022. This law requires us to provide you with a “good faith estimate” of the total cost of your treatment. Estimating the total cost of psychiatric and psychotherapy treatment is very difficult because the course of treatment varies for everyone. The law requires us to make this estimate prior to completing an assessment which further complicates things. In psychiatry and psychotherapy, there are only a handful of CPT codes (billing codes) that can be used and the prices for those codes do not vary. Attached you will find a good faith estimate of your treatment.

You have a right to receive a “Good Faith Estimate” explaining how much your medical care will cost.

Under the law, healthcare providers need to give patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services.

  • You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes related costs, like medical tests, prescription drugs, equipment, and hospital fees.

  • Make sure your health care provider gives you a Good Faith Estimate in writing at least 1 business day before your medical service or item. You can also ask your healthcare provider, and any other provider you choose, for a Good Faith Estimate before you schedule an item or service.

  • If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill.

The purpose of this document is to let you know about your protections from unexpected medical bills. It also asks whether you would like to give up those protections and pay more for out-of-network care.

Important: You are not required to sign this form and shouldn’t sign it if you didn’t have a choice of health care provider when you received care. You can choose to get care from a provider or facility in your health plan’s network, which may cost you less. If you’d like assistance with this document, ask your provider. Take a picture and/or keep a copy of this form for your records.

You’re getting this notice because this physician isn’t in your health plan’s network. This means the physician and the facility doesn’t have an agreement with your plan. Getting care from this physician/facility could cost you more. Ask your health care provider if you need help knowing if these protections apply to you.

If you sign this form, you may pay more because:

  • You are giving up your protections under the law

  • You may owe the full costs billed for items and services received

  • Your health plan might not count any of the amount you pay towards your out-of-pocket limit. Contact your health plan for more information.

You shouldn’t sign this form if you didn’t have a choice of providers when receiving care. For example, if a doctor was assigned to you with no opportunity to make a change. Before deciding whether to sign this form, you can contact your health plan to find an in-network provider or facility. If there isn’t one, your health plan might work out an agreement with this physician or another one. See below for your cost estimate.

Estimate Of What You Could Pay:

  • Review your detailed estimate

  • Call your health plan. Your plan may have better information about how much you will be asked to pay. You also can ask about what’s covered under your plan and your provider options.

  • Questions about this notice and estimate? Call 904-733-7333 or email info@vijapura.com

By signing, I give up my federal consumer protections and agree to pay more of out-of-network care. With my signature, I am saying that I agree to get the items or services from:

Vijapura Psychiatry

With my signature, I acknowledge that I am consenting of my own free will and am not being coerced or pressured. I also understand that:

  • I’m giving up some consumer billing protections under federal law

  • I will get a bill for the full charges for these items and services, or have to pay out-of-network.

  • I was given a written notice explaining that my provider or facility isn’t in my health plan’s network, the estimated cost of services, and what I may owe if I agree to be treated by this provider or facility.

  • I got the notice either on paper or electronically, consistent with my choice.

  • I fully and completely understand that some or all amounts I pay might not count toward my health plan’s deductible or out-of-pocket limit

  • I can end this agreement by notifying the provider or facility in writing before getting services.

Important: You don’t have to sign this form. But if you don’t sign, this provider or facility might not treat you. You can choose to get care from a provider or facility in your health plan’s network.

Good Faith Estimate

The amount below is only an estimate; it isn’t an offer or contract for services. This estimate shows the full estimated costs of the items or services listed. It doesn’t include any information about what your health plan may cover for out-of-network providers. This means that the final cost of services may be different than this estimate. You and your psychiatrist will determine the frequency of appointments together based on your needs. This may vary depending on whether you receive services for medication management, therapy, or both. We are concerned that there will be an element of “sticker shock.” Seeing the total cost of a year’s work of treatment can be alarming, but there is no guarantee that you will be in treatment for a full year. Please keep in mind that this estimate does NOT account for any potential out-of-network reimbursement from your insurance carrier.

Please be aware of the following maximum out-of-pocket scenarios:

Medication management with brief psychotherapy: typically requires an initial 45 minutes to 1 hour appointment ($450), plus on average monthly up to 20 minute follow-up appointments at $225 each. This could lead to a total of $3150 over a 12 month period of time.

You should also be aware that, since we charge for “other professional services” (described in the new patient contract), this may add additional out-of-pocket costs. While it is impossible to predict the exact amount of professional services a patient may need outside of their appointments.

The totals below are OVERESTIMATIONS for the vast majority of patients, but we want you to be aware of the possible out-of-pocket maximum costs over 12 months should you require that amount of care:

Medication management with brief psychotherapy: $3150

It is based on once-monthly appointments for a year, you may attend appointments less frequently than this and your cost would be less, you may attend appointments more frequently than this and your cost would be more.

The estimated costs are valid for 12 months from the date of the Good Faith Estimate.

The following are our fees for services, you estimate is being based on the fact that you are scheduled to see a Psychiatrist (M.D.), Psychiatric PA or Psychiatric Nurse Practitioner.

60 min

Intake

99204

$450

10-20 min

Session

99214

$225

99204: Intake Session: $450 x 1 unit = $450

99214: Follow-up Sessions: $225 x 12 months = $2,700

Total expected cost* = $3,150

*This does not account for any potential reimbursement from your insurance carrier.

Vijapura Behavioral Health PLLC
9141 Cypress Green Drive, Ste 1
Jacksonville, FL 32256
NPI: 1376904557 FEIN: 47-405-9133

Disclaimer: This Good Faith Estimate shows the costs of the items and services that are reasonably expected to be 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. Federal law allows you to dispute (appeal) the bill if this happens. If you are billed for more than this Good Faith Estimate, you have the right to dispute the bill.

You may contact the health care provider or facility listed to let them know the billed charges are higher than the Good Faith Estimate. You can ask them to update the bill to match the Good Faith Estimate, ask to negotiate the bill or ask if there is financial assistance available.

You may also start a dispute resolution process with the US Department of Health and Human Services (HHS). If you choose to use the dispute resolution process, you must start the dispute process within 120 days (about 4 months) of the date on the original bill. There is a $25 fee to use the dispute process. If the agency reviewing your dispute agrees with you, you will have to pay the price on this Good Faith Estimate. If the Agency disagrees with you and agrees with the health care provider or facility, you will have to pay the higher amount.

To learn more and get a for to start the process go to www.cms.gov/nosurprises.

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