Important to Note:

Insurance: I will do my best to look up your benefits for insurance. They are not always accurate. It is the client’s responsibility to call and verify their benefits. CPT codes I generally use to ask about when you call are 90837, 90847 or 90834 for therapy sessions, and 90791 for initial session. To determine if you have mental health coverage, the first thing you should do is check with your insurance carrier. Check your coverage carefully and find the answers to the following questions:

• What are my mental health benefits? Is Nicolle in-network? Do I have a deductible to meet? Do I have a copay or coinsurance fee? How many therapy sessions does my plan cover? How much does my insurance pay for an out-of-network provider (if using OON)? Is approval required from my primary care physician?

Insurance Disclaimer: While I try to be as accurate as possible when verifying benefits, your fees may change depending on your eligibility and benefits during the date of your sessions. If I provide an estimate, I won't know your exact fee until I bill your insurance and get your explanation of benefits back from your insurance company. You are also encouraged to call the number on the back of your insurance card and ask your member representative about your 'mental health, outpatient, office visit' benefits. You are responsible for any fee not covered by insurance at the time of service.

Once I contact you, I will send you an invite to create a client portal from a HIPPA compliant EHR called Therapy Notes. Please fill out all required intake forms before our first visit.

GOOD FAITH ESTIMATES: For self-pay clients (no insurance)

There is a new law, called The No Surprises Act, that began January 1, 2022. Under this law, you have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost, if you do not have insurance, or if you are choosing to opt out of using your insurance.

This act applies to all certified and licensed medical and behavioral health professionals across the country who serve patients and clients who do not have insurance, or who are choosing to opt out of using active insurance benefits. 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.

A Good Faith Estimate is currently not required for patients and clients who are choosing to use their insurance with an in-network provider, but I will happily provide you with one for all out of network services.

If you request a Good Faith Estimate from me or any other healthcare provider you’re working with, make sure you receive it in writing at least 1 business day before your medical service or therapy session. You also have the right to ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule an item or service.

You have the right to dispute the bill you receive if it ends up being at least $400 more than your Good Faith Estimate.

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.

CONFIDENTIALITY AND PRIVACY POLICY

The law protects the relationship between a client and a psychotherapist, and information cannot be disclosed without written permission.

Exceptions include:

• Suspected child abuse or dependant adult or elder abuse, for which I am required by law to report this to the appropriate authorities immediately.

• If a client is threatening serious bodily harm to another person/s, I must notify the police and inform the intended victim.

• If a client intends to harm himself or herself, I will make every effort to enlist their cooperation in ensuring their safety. If they do not cooperate, I will take further measures without their permission that are provided to me by law in order to ensure their safety.