Forms

Forms

The No Surprises Act went into effect January 1, 2022, and requires all healthcare providers to notify clients of their federal rights and protections against “surprise billing” when services are rendered by an out-of-network provider, if you are uninsured, or you elect to not use insurance.

When you begin or resume treatment you will be asked to sign the Standard Notice and Consent For non-Participating Provider, which includes a “Good Faith Estimate”, and was adapted from the Center for Medicare Services Website No Surprises Act | CMS. (include hyperlink- https://www.cms.gov/nosurprises)

You are entitled to receive a “Good Faith Estimate” for the expected cost of non-emergency, psychotherapy services. While it is not possible for a psychotherapist to know, in advance, how many psychotherapy sessions may be necessary or appropriate for a given person, this form provides an estimate of the per session cost of services provided. Your total cost of services will depend upon the number of psychotherapy sessions you attend, your individual circumstances, and the type and amount of services that are provided to you. This estimate is not a contract and does not obligate you to obtain any services from the provider(s) listed, nor does it include any services rendered to you that are not identified here.

This Good Faith Estimate is not intended to serve as a recommendation for treatment or a prediction that you may need to attend a specified number of psychotherapy visits. The number of visits that are appropriate in your case, and the estimated cost for those services, depends on your needs and what you agree to in consultation with your therapist. You are entitled to disagree with any recommendations made to you concerning your treatment and you may discontinue treatment at any time.



1518 Walnut Street Suite 1100
Philadelphia, PA 19102

info@melanatedwomenshealth.com
(215) 720-1456

Got Questions?
Send a Message!

By submitting this form via this web portal, you acknowledge and accept the risks of communicating your health information via this unencrypted email and electronic messaging and wish to continue despite those risks. By clicking "Yes, I want to submit this form" you agree to hold Brighter Vision harmless for unauthorized use, disclosure, or access of your protected health information sent via this electronic means.