North Berkeley Counseling Collective - No Surprises Act

Telegraph Psychology Collective/ North Berkeley

Counseling Collective Notice of GFE for Self-Pay

Clients

GOOD FAITH ESTIMATE NOTICE

You have the right to receive a “Good Faith Estimate” explaining the expected cost of

your health care.

Under the federal No Surprises Act, health care providers generally must provide a Good

Faith Estimate to individuals who are not enrolled in a health plan or other health care

coverage, or who are enrolled but do not intend to have a claim submitted to their health

plan for the services at issue.

If these requirements apply to you, Telegraph Psychology Collective, PC, doing business

as North Berkeley Counseling Collective (“the Practice”), will provide you with a written

Good Faith Estimate when your services are scheduled sufficiently in advance or when

you request an estimate. You may request a Good Faith Estimate before scheduling

services.

Your Good Faith Estimate will describe the services reasonably expected to be provided

and the anticipated charges based on the information known when the estimate is

prepared. Because psychotherapy is individualized, the length, frequency, and total

duration of treatment cannot always be predicted in advance. An estimate for recurring

psychotherapy may therefore be based on an anticipated frequency and period of

treatment. Your treatment needs, preferences, schedule, or recommended level of care

may change over time.

Template library

Intake documents, progress notes, treatment plans, and other documents

A Good Faith Estimate is not a contract and does not require you to obtain the services

listed in the estimate. It does not prevent you and your Treating Clinician from agreeing

to different or additional services. If the expected services or charges materially change,

Shareable documents

the Practice may provide an updated Good Faith Estimate.

Manage default intake documents and uploaded files

You may incur charges not included in an earlier estimate if you request or receive

additional services, including longer sessions, family or collateral sessions, reports,

record preparation, consultations, court or legal services, psychological testing, missed-

appointment fees, or other separately agreed-upon services. When reasonably possible,

the Practice will inform you of additional charges before providing the service.

If you receive a bill from the Practice that is at least $400 more than the total expected

charges listed in the applicable Good Faith Estimate, you may be eligible to dispute the

bill through the federal patient-provider dispute-resolution process.

Please retain a copy of every Good Faith Estimate you receive.

For questions about your estimate or to request a Good Faith Estimate, contact:

Telegraph Psychology Collective, PCDBA North Berkeley Counseling Collective

Telephone: 510-224-5591

Email: hello@telegraphpsychology.com

For additional information about Good Faith Estimates and your rights under the No

Surprises Act, visit www.cms.gov/nosurprises.

ACKNOWLEDGMENT OF RECEIPT

By signing below, I acknowledge that I received this Good Faith Estimate Notice. I

understand that this acknowledgment does not waive any rights I may have under

federal or state law.