Standard Notice: “Right to Receive a Good Faith Estimate of Expected Charges” Under the No Surprises Act
(For use by health care providers no later than January 1, 2022)

Instructions
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.


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 1 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

Provider Name- Kathryn Lyndsey Osler, LMFT                                                       NPI- 1932465085 -                                                                                                   License State and Number- MN #3957 NC#1516                                                 TAX ID - 85-3124210
 
Common Diagnoses Lyndsey Osler, LMFT treats at C3 Therapy, PLLC

Z13.30 Encounter for screening examination for mental health and behavioral disorders, unspecified
F43.20: Adjustment Disorder, Unspecified
262.820: Parent-Child Relational Problem
Z63.0: Relationship Distress with Spouse or Intimate Partner
262.89: Phase of Life Problem
Z91.49: Other Personal History of Pyschological Trauma
F41.1 Generalized anxiety disorder ·
F90.9 Attention-Deficit Hyperactivity Disorder, Unspecified Type

A note about diagnosis
At C3 Therapy, PLLC, Lyndsey does not typically diagnose clients unless she believes a specific diagnosis to be accurate after evaluation and, after consultation with the client, Lyndsey believes that having a mental health diagnosis is likely in the client's best interest. Instead of using diagnostic codes, Lyndsey typically use Z codes which represent general areas of concern to be addressed in therapy. Please speak to Lyndsey about this practice if you have questions or concerns.

Common Service and Service Codes used at C3 Therapy, PLLC
90791: Therapy Intake
90834: 60 minute counseling/psychotherapy session
90847: 60 minute counseling/psychotherapy session

The above mentioned provider estimates that the total cost of services rendered over a 12 month period will be:

1 session per week at $165.00 per hour for 52 weeks
Total estimate cost $8580.00
Services will be conducted at either 6607 18th ave south Richifield MN 55347 or at the client's address entered above via Zoom.

Disclaimer

This Good Faith Estimate shows the costs of items and services that are reasonably expected for your health care needs for an item or service. The estimate is based on information known at the time the estimate was created.
The Good Faith Estimate does not include any unknown or unexpected costs that may arise during treatment. You could be charged more if complications or special circumstances occur. If this happens, federal law allows you to dispute (appeal) the bill.

If you are billed for more than this Good Faith Estimate, you have the right to dispute the bill.
You may contact the health care provider or facility listed 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 U.S. 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 on the original bill.

There is a $25 fee to use the dispute process. If the agency reviewing your dispute agrees with you, you will have to pay the price on this Good Faith Estimate. If the agency disagrees with you and agrees with the health care provider or facility, you will have to pay the higher amount.

To learn more and get a form to start the process, go to
www.cms.gov/nosurprises 
For questions or more information about your right to a Good Faith Estimate
or the dispute process, visit www.cms.gov/nosurprises

Keep a copy of this Good Faith Estimate in a safe place or take pictures of it. You may need it if you are billed a higher amount.