LisaYee-forms.jpg
LisaYee-forms.jpg

FORMS & FEES


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FORMS & FEES


Important Forms

I will provide you with a link to the forms online once there is an established appointment. These forms are to be used for those who do not have access to the internet or by my direction.

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For the First Session:
Client Intake
Acknowledge of Receipt of Notice of Privacy Practices — HIPPA
Informed Consent for Treatment

For Your Review:
Notice of Privacy

Forms to Be Completed Upon Request:
Authorization for Release

GOOD FAITH ESTIMATE

Under Section 2799B-6 of the Public Health Service Act, health care providers and health care facilities are required to inform individuals who are not enrolled in a plan or coverage or a Federal health care program, or not seeking to file a claim with their plan or coverage both orally and in writing of their ability, upon request or at the time of scheduling health care items and services, to receive a “Good Faith Estimate” of expected charges.

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

Under the law, health care 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 health care 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.

  • Make sure to save a copy or picture of your Good Faith Estimate. For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises

FEES


FEES


“FEES”

Payment is due at the beginning of each session unless different arrangements have been made so that we can use the full session for therapy. I accept cash, checks, and all major credit cards. My fees range between $175.00 and $260.00 per session depending on session length and type of session.

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“INSURANCE”

I do not participate with any insurance panels. I can provide you with a receipt that you can submit to your Flexible Spending Plan or your insurance if they accept out-of-network providers. It is your responsibility to check with your insurance provider about your coverage for out-of-network providers and their services. You retain ultimate responsibility for payment for services if your insurance company decides not to reimburse you and payment will be taken at time of session.

MAP


MAP