CLIENT PORTAL The following link will provide access & directions for creating a private client portal: https://www.jituzu.com/site/el...
INTAKE FORMS
Informed Consent & Privacy Practices
HIPPA Notices of Privacy Practices
Telehealth Consent Form
Release of Information Consent Form
NO SURPRISES ACT & GOOD FAITH ESTIMATES
The No Surprises Act took effect on January 1, 2022, which requires mental healthcare professionals to provide Good Faith Estimates to uninsured, out-of-network, and/or self-paying clients for services offered when scheduling care or at the request of the client. A Good Faith Statement will be provided at the time of scheduling and/or at initial intake session. This Good Faith Estimate shows the costs of items & services that are reasonably expected for presented mental health care needs.
Estimates are made based on information given at the time estimates are created. The Good Faith Estimate does not include any unknown or unexpected costs. Additional charges may occur if complications or special circumstances are presented. If this happens, and your bill is $400 or more than your Good Faith Estimate, federal law allows you to dispute the bill. You may contact the health care provider 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 calendar days (about 4 months) of the date of the original bill.
If you dispute you bill, the provider cannot move the bill for disputed item or services into collection, or threaten to do so; or if the bill has already moved into collection, the provider has to cease collection efforts. The provider must also suspend the accrual of any late fees on unpaid bills amounts until after the dispute resolution process has concluded. The provider cannot take or threaten to take any retributive action against you for disputing the bill. There is a $25 fee to use the dispute process. If the Selected Dispute Resolution (SDR) entity reviewing your dispute agrees with you, you will have to pay the price on the Good Faith Estimate, reduced by the $25 fee. If the SDR entity disagrees with you and agrees with the health care provider, you will have to pay the higher amount.
To learn more and get a form to start the process, go to www.cms.gov/nosurprisesact/con... or call 1-800-985-3059. For questions or more information about your right to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprisesact/con..., email [email protected], or call 1-800-985-3059
PRIVACY ACT STATEMENT: CMS is authorized to collect the information on this form and any supporting documentation under section 2799B-7 of the Public Service Act, as added by section 112 of the No Surprises Act, title I of Division BB of the Consolidated Appropriations Act, 2021 (Pub. L. 116-260). We need the information of your form to process your request to initiate a payment dispute, verify the eligibility of your dispute for the PPDR process, and to determine whether any conflict of interest exists with the independent dispute resolution entity selected to decide your dispute. The information may also be used to: 1) support a decision on your dispute, 2) support the ongoing operation and oversight of the PPDR program, and 3) evaluate selected IDR entity's compliance with program rules. Providing the requested information is voluntary, but failing to provide it may delay or prevent processing of your dispute, or it could cause your dispute to be decided in favor of the provider.