Good Faith

James J. De Santis, Ph.D.
Post Office Box 894, Glendora, CA 91740-0894
(818) 551-1714

The reader is welcome to print any screen from this website for personal
use only as long as author, copyright, and contact information are not
removed.

Notice on Cost of Services

We would like to let you know about your legal protection from
unexpected medical bills. We want to inform you that you may
receive services at lower cost from another provider within your
insurance network.

Purpose of This Notice

The Federal "No Surprises Act" went into effect on January 1,
2022. The law was intended to prevent surprise medical bills
when patients unknowingly obtain services from providers outside
their health insurance network.

Under the law, health care providers are required to give a good
faith estimate of cost to patients who don't have insurance or
who are not using insurance.

You are receiving this notice because your psychologist is not in
your insurance network, meaning he doesn't have an agreement
with your plan.

Standard Charges for Services in This Office

Our current fee schedule is listed in our consent forms. Fees may
be periodically adjusted with prior notice.

Estimate of Cost

You have the right to receive a good faith estimate explaining
how much your medical care will cost.

Because psychotherapy is usually a recurring service, the total
cost is generally the number of sessions multiplied by the session
fee. This estimate is based on one year of service.

This estimate does not calculate or subtract the amount your
health insurance may reimburse you. Some insurance plans may
cover a portion of the charge.

This is not a contract for services. You can discontinue services
at any time.

You are not obligated to pay any amount ahead of time. You are
not obligated to pay the total estimated cost if you do not use
the services.

Insurance Claims

Determining what portion of cost which your insurance may
reimburse is your responsibility.

Please let us know if you plan to submit a claim to your insurance
for services. As a courtesy, we would be happy to generate a
receipt---a statement or "superbill"---for you to submit to your
insurance for out-of-network reimbursement.

Respecting Your Health Care Choices

If you use a network provider, your cost of services may be less
than using an out-of-network provider. You may incur lower
annual deductibles and higher rates of reimbursement for an
in-network provider.

You may choose to see Dr. De Santis as an out-of-network
provider based on other factors, such as difficulty finding an
in-network provider with availability for new patients or a
decision that your work with Dr. De Santis will more quickly
accomplish your goals.

Limitations of An Estimate of Cost

The estimate shows the cost of services that are reasonably
expected for your health care needs. The actual total number of
sessions is unknown at the outset. This estimate may be
different, depending on a number of factors.

The estimate does not include any unknown or unexpected costs
that may arise during treatment. The actual cost is subject to
change due to changes in the frequency and duration of
services. Frequency and duration of services may vary based on
complications or special circumstances that arise regarding your
issues or the severity of your symptoms, a new emerging
condition, a change in diagnosis, changes in the frequency of
appointments, social or environmental factors that may help or
hinder your progress, your motivation and effort, and your
decisions about treatment.

The cost also may be adjusted based on financial need.

Research indicates the average length of a course of
psychotherapy may be from a few weeks to a few years.

We respect your right to determine your goals for treatment and
how long you would like to remain in therapy. We always
welcome discussion about frequency and duration of services.

Appeals

You are welcome to dispute the charges if they are more than
the estimate. You can ask them to update the bill to match the
estimate, ask to negotiate the bill, or ask if financial assistance
is available.

If the actual cost of services in this office exceeds the estimate
by more than $400, you are invited to discuss your concerns
with the psychologist about the increased amount.

You may also initiate a dispute resolution process with the US
Department of Health and Human Services within 120 calendar
days from the date of the original bill. There is a $25 fee to use
the process. If the agency reviewing your dispute agrees with
you, you will have to pay the price on this estimate. If the
agency disagrees with you, you will have to pay the higher
amount. To start the process, go to
www.cms.gov/nosurprises/consumers or call (800) 985-3059.

Informed Consent

You are not required to sign this consent. You can discontinue
services at any time.

By seeing Dr. De Santis, you are accepting that you may be
paying more for services than going to an in-network provider.
You are accepting that your insurance might not count some or
all of the amount you pay toward your deductible or out-of
pocket limit.

Before deciding whether to agree to services, you are welcome
to contact your insurance to get information about how much of
these services are reimbursable or to find an in-network provider
or facility. You are not required to receive care from your
psychologist.

Except in an emergency, your health plan may require prior
authorization (or other limitations) for certain services. This
means you may need your plan's approval that it will cover a
service before you receive it. If prior authorization is required,
ask your health plan about what information is necessary to get
coverage.

Please keep a copy of this page for your records.

Further Information

• Centers for Medicare and Medicaid Services, (877) 267-2323
or www.cms.gov/nosurprises.

• US Department of Health & Human Services, (877) 696-6775
or www.hhs.gov.

• California Department of Insurance, (800) 927-4357 or
www.insurance.ca.gov.