Good Faith Estimate
The No Surprises Act of 2020 is intended to protect healthcare consumers from “surprise” medical bills incurred at larger healthcare facilities for services provided by out-of-network providers at these facilities. I am required to provide you with this “Good Faith Estimate” of the cost of our services.
Fees are clearly outlined in our Practice Agreement. However, with the course of mental illness and the response to treatment being variable, it’s difficult to predict the cost of our services with certainty, because appointments may need to become more frequent or less frequent, depending on the progress being made. As required by the No Surprises Act, we can offer estimations of what our services will cost you in the following hypothetical scenarios, extrapolated to a 12-month/52-week treatment period:
Initial Assessment + WEEKLY Individual Therapy (60 min): $6,575
Initial Assessment + BI-WEEKLY Individual Therapy (60 min): $3,450
Initial Assessment + WEEKLY Couples/Family Therapy (60 min): $10,400
Initial Assessment + BI-WEEKLY Couples/Family Therapy (60 min): $5,200
Initial Assessment + MONTHLY Individual Therapy (60 min):$1,700
Initial Assessment + MONTHLY Couples/Family Therapy (60 min):$2,600
Please understand that these estimates are our ‘best guess’ as to what treatment may cost, and carefully consider which of these services apply to you. The cost of “Between-appointment correspondences” such as phone calls or paperwork are not included because these are highly variable and often negligible or totally absent. 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 provider. You are entitled to disagree with any recommendations made to you concerning your treatment and you may discontinue treatment at any time.
If you are billed for more than this Good Faith Estimate, you have the right to dispute the bill.
You may contact us to let us know the billed charges are higher than the Good Faith Estimate. You can ask us 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 U.S. Department of Health and Human Services (HHS). You have a right to initiate a dispute resolution process if the actual amount charged to you substantially exceeds the estimated charges stated in your Good Faith Estimate (which means $400 or more beyond the estimated charges). If you choose to use the dispute resolution process, you must start the dispute process within 120 calendar 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 form to start the process, go to www.cms.gov/nosurprises.
Before or at the time of collecting personal information, I will identify the purposes for which information is being collected. I will only retain personal information as long as necessary for the fulfillment of those purposes.
I will collect and use personal information solely with the objective of fulfilling those purposes specified by me and for other compatible purposes, unless I obtain the consent of the individual concerned or as required by law (see below). I will protect personal information by reasonable security safeguards, as well as unauthorized access, disclosure, copying, use or modification.
LINKS TO OTHER WEBSITES
I reserve the right to disclose your personally identifiable information as required by law, when I believe that disclosure is necessary to protect our rights, and/or to comply with a judicial proceeding, court order or other legal process.
CHANGES TO OUR POLICY
Times change, as do privacy expectations. I consider this a living document, and may modify or update this policy from time to time, so please review it periodically. I may provide you additional forms of notice of modifications or updates as appropriate under the circumstances, as a courtesy only. Your continued use of this site after any modification to this policy will constitute your acceptance of such modification.
Social Media Policy
This document outlines my office policies related to use of Social Media. Please read it to understand how I conduct myself on the Internet as a mental health professional and how you can expect me to respond to interactions that may occur between us on the Internet. Please discuss any questions or concerns you may have with me directly.
Amanda Hembree, LP(C)C, CEAP holds separate and isolated accounts to be used for the sole purpose of professional matters regarding Lagniappe Counseling. These accounts are separate from any personal accounts held by Amanda Hembree as an individual.
Please use email to contact me for administrative reasons only (modifying appointments, billing information, etc.). Please do not email content related to our counseling sessions, unless otherwise discussed. Email communication is not completely secure or confidential. Any emails I receive from you and any responses I send to you become a part of your legal record.
Please do not send text messages, unless otherwise agreed upon. I will not respond to texting. Any text message I receive from you becomes a part of your legal record. Traditional text messaging is not considered HIPAA compliant.
I will not follow any client on personal Twitter, Instagram, blogs, or other apps/websites. If there is content you wish to share from your online life, please bring it into our sessions where we can explore it together.