Fees & Forms

All fees are due at the time of service. I am not in-network with any health insurance. Some insurance companies have out-of-network benefits. You should contact your insurance company to determine your specific plan benefits. I am happy to provide you with a receipt called a “super bill” that you can submit to your insurance carrier for potential reimbursement. We can discuss any questions you have about fees, insurance, and payment options during our initial consultation.

  • Intake Assessment, 60 minutes, $250

  • Individual Therapy, 50 minutes, $200

  • Bariatric Pre-surgical Evaluation, $500

  • Transgender Consultation and Evaluation, $500

 

Online and In-Person Appointments Available --

Online and In-Person Appointments Available --

Forms for Your First Appointment

Please complete the forms below and either email them to me or bring them to your first appointment. Feel free to be in touch if you have any questions!

 

Your Rights and Protections Against Surprise Medical Bills

  • When you see a doctor or other health care provider, you may owe certain out-of-pocket costs, such as a copayment, coinsurance, and/or a deductible. You may have other costs or have to pay the entire bill if you see a provider or visit a health care facility that isn’t in your health plan’s network.

    “Out-of-network” describes providers and facilities that haven’t signed a contract with your health plan. Out-of-network providers may be permitted to bill you for the difference between what your plan agreed to pay and the full amount charged for a service. This is called “balance billing.” This amount is likely more than in-network costs for the same service and might not count toward your annual out-of-pocket limit.

    “Surprise billing” is an unexpected balance bill. This can happen when you can’t control who is involved in your care—like when you have an emergency or when you schedule a visit at an in- network facility but are unexpectedly treated by an out-of-network provider.

  • Emergency services

    If you have an emergency medical condition and get emergency services from an out-of- network provider or facility, the most the provider or facility may bill you is your plan’s in- network cost-sharing amount (such as copayments and coinsurance). You can’t be balance billed for these emergency services. This includes services you may get after you’re in stable condition, unless you give written consent and give up your protections not to be balanced billed for these post-stabilization services.

    Certain services at an in-network hospital or ambulatory surgical center

    When you get services from an in-network hospital or ambulatory surgical center, certain providers there may be out-of-network. In these cases, the most those providers may bill you is your plan’s in-network cost-sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services. These providers can’t balance bill you and may not ask you to give up your protections not to be balance billed.

    If you get other services at these in-network facilities, out-of-network providers can’t balance bill you, unless you give written consent and give up your protections.

    You’re never required to give up your protections from balance billing. You also aren’t required to get care out-of-network. You can choose a provider or facility in your plan’s network.

  • You are only responsible for paying your share of the cost (like the copayments, coinsurance, and deductibles that you would pay if the provider or facility was in-network). Your health plan will pay out-of-network providers and facilities directly.

  • Cover emergency services without requiring you to get approval for services in advance (prior authorization).

    Cover emergency services by out-of-network providers.

    Base what you owe the provider or facility (cost-sharing) on what it would pay an in-network provider or facility and show that amount in your explanation of benefits.

    Count any amount you pay for emergency services or out-of-network services toward your deductible and out-of-pocket limit.

  • Visit www.cms.gov/nosurprises or call 404-600-0864.

STANDARD NOTICE

“Right to Receive a Good Faith Estimate of Expected Charges” Under the No Surprises Act

 

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 one 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 or call 404-600-0864.