Good Faith Estimate – Jared Dalton

GOOD FAITH ESTIMATE FOR HEATHCARE ITEMS AND SERVICES

In compliance with the No Surprises Act that went into effect January 1, 2022, all healthcare providers are required to notify clients of their federal rights and protections against “surprise billing.”

This Act requires that we notify you of your federally protected rights to receive a notification when services are rendered by an out-of-network provider, if a client is uninsured, or if a client elects not to use their insurance.

Additionally, we are required to provide you with a Good Faith Estimate of the cost of services (attached). It is difficult to determine the true length of treatment for mental health care, and each client has a right to decide how long they would like to participate in mental health care. Therefore, attached you will find a fee schedule
for services typically offered, and we will collaborate with you on a regular basis to determine how many sessions you may need.

Your signature will indicate your acknowledgement of the receipt of the form. The Good Faith Estimate does not require the private pay patient to obtain services from Axon Health Associates. This is not a contract for services. The Good Faith Estimate of fees listed does not include any information about what your health plan may cover and does not reflect your eligibility for a reduced fee. This means that the final cost of services may be different than this estimate.

It is a federal requirement that we have each client sign this form to begin/resume treatment. Please sign and date this form before your next appointment and return the signed document to Axon Health Associates. If you have any questions, please do not hesitate to ask.

The No Surprises Act Standard Notice & Consent
OMB Control Number: 0938-140

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. The purpose of this document is to let you know about your protections from unexpected medical bills. It also asks whether you would like to give up those protections and pay more for out-of-network care.

You are getting this notice because this provider or facility is not in your health plan’s network. This means the provider or facility does not have an agreement with your plan.

Getting care from this provider or facility could cost you more.

If your plan covers the item or service you are getting, federal law protects you from higher bills:

• When you get emergency care from out-of-network providers and facilities, or
• When an out-of-network provider treats you at an in-network hospital or ambulatory surgical center without your knowledge or consent.

Ask your health care provider or patient advocate if you need help knowing if these protections apply to you. If you sign this form, you may pay more because:

• You are giving up your protections under the law.
• You may owe the full costs billed for items and services received.
• Your health plan might not count any of the amount you pay towards your deductible and out-of-pocket limit. Contact your health plan for more information.

You should not sign this form if you did not have a choice of providers when receiving care. For example, if a doctor was assigned to you with no opportunity to make a change.

Before deciding whether to sign this form, you can contact your health plan to find an in-network provider or facility. If there is not one, your health plan might work out an agreement with this provider or facility, or another one.

Total cost estimate of what you could be asked to pay:

It is your ethical right to determine your goals for treatment and how long you would like to remain under care unless you are pursuing mandatory treatment. Please see the breakdown of possible fees on page five.

• Review your detailed estimate. See page five for a cost estimate for each item or service.
• Call your health plan. Your plan may have better information about how much of these services are reimbursable.
• Questions about this notice and estimate? Call 317-818-9000 or write to officemanager@axonhealth.org.
• Questions about your rights? Contact the Indiana Secretary of State at 317-232-6531. For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises or call 1-800-985-3059.

Prior authorization or other care management limitations:

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

More information about your rights and protections:
Visit https://www.cms.gov/files/document/model-disclosure-notice-patient-protections-against-surprise-billing- providers-facilities-health.pdf for more information about your rights under federal law.

GOOD FAITH ESTIMATE TABLE OF SERVICES AND FEES

With my signature, I am saying that I agree to get items or services from:
✓ Dr. Jerad Dalton, D.O.
Services will be provided online via telehealth or in person at 9245 North Meridian Street, Suite 225 Indianapolis, IN 46260.

Frequency and Expected Duration of Services

At Axon Health Associates, we recognize that every person’s journey is unique. How long and how often you need to engage in sessions can be influenced by several factors: your schedule, provider availability, ongoing life challenges, personal finances, etc. We expect that your care will require approximate monthly sessions, at the below stated cost per session for a total of one year; accounting for vacations, holidays, cancellations/sickness, and other circumstances. Not all clients require monthly sessions, and as such, as we continue in our work together, we will discuss your specific needs.

Common Diagnosis Codes at Axon Health Associates (this is not an all-inclusive list)

F84.0: Autism Spectrum Disorder
F90.0-F90.9: Attention Deficit Hyperactivity Disorder F34.8: Disruptive Mood Dysregulation Disorder F43.20: Adjustment Disorder, Unspecified
F32.0-F33.9: Depressive Disorders
F31.11-F31.81: Bipolar Disorder and Related Disorders F41.1: Generalized Anxiety Disorder
F41.9: Anxiety Disorder, Unspecified
F43.1: Post-Traumatic Stress Disorder (PTSD) Z62.820: Parent/Child Relational Conflict

Estimated Cost of Services

The amount below is only an estimate; it is not an offer or contract for services. This estimate shows the full estimated costs of the items or services listed. It does not include any information about what your health plan may cover and does not reflect your eligibility for a reduced fee. This means that the final cost of services may be different than this estimate. Contact your health plan to find out how much, if any, your plan will pay or reimburse for out-of-network benefits.

This Good Faith Estimate explains your provider’s rate for each service provided. Your provider will collaborate with you throughout your treatment to determine how many sessions and/or services you may need to receive the greatest benefit based on your presenting concerns.

DISCLAIMERS AND YOUR RIGHTS

By signing this document, I give up my federal consumer protections and agree I might pay more for out-of- network care.

With my signature, I acknowledge that I am consenting of my own free will and am not being coerced or pressured. I also understand that:

• I am giving up some consumer billing protections under federal law.
• I may get a bill for the full charges of these items and services or have to pay out-of-network cost- sharing under my health plan.
• I was given written notice at least 72-hours prior to the initial appointment date explaining that my provider or facility is not in my health plan’s network, the estimated cost of services, and what I may owe if I agree to be treated by this provider or facility.
• I received the notice in written or electronic format, consistent with my choice.
• I fully and completely understand that some or all amounts I pay might not count toward my health plan’s deductible or out-of-pocket limit.
• I can end this agreement by notifying the provider or facility in writing before getting services.

You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. If you received a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill.