Self Elements Psychotherapy & Wellness

35 Beaverson Blvd. Suite 4D

Brick. NJ 08723

908-373-1059

THE NO SURPRISES ACT 

STANDARD NOTICE AND CONSENT DOCUMENT 

(WITH GOOD FAITH ESTIMATE) 

(OMB Control Number: 0938-1401) 

SURPRISE BILLING PROTECTION FORM 

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’re getting this notice because this provider isn’t in your health plan’s network. This means the provider or facility doesn’t have an agreement with your plan. 

Getting care from this provider could cost you more. 

If your plan covers the item or service you’re 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 healthcare 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 shouldn’t sign this form if you didn’t 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 isn’t one, your health plan might work out an agreement with this provider or facility, or another one. 

See the next page for your cost estimate.

Estimate of what you could pay 

Patient name: 

Out-of-network provider: Self Elements Psychotherapy & Wellness

Total cost estimate of what you may be asked to pay: It is your ethical right to determine your goals for treatment and how long you would like to remain in therapy unless you are pursuing mandatory treatment. Please see the breakdown of possible fees on page four. 

►Review your detailed estimate. See page four 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 Kerri Russell-Russo, MSW, LCSW 908-373-1059

►Questions about your rights? Contact: The NJ State Board of Social Work Examiners  at 973-504-6495 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-billi ng-providers-facilities-health.pdf for more information about your rights under federal law.

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

With my signature, I am saying that I agree to get the items or services from: ☐ Self Elements Psychotherapy & Wellness

☐ 

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’m giving up some consumer billing protections under Federal law. 
• I may get a bill for the full charges for these items and services or have to pay out-of-network cost-sharing under my health plan. 
• I was given a written notice on _______________(Date) explaining that my provider or facility isn’t 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 got the notice either on paper or electronically, 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. 

IMPORTANT: You don’t have to sign this form. But if you don’t sign, this provider might not treat you. 

_ Client’s signature 

_____________________________________ Guardian/authorized representative’s signature Print name of client Print name of guardian/authorized representative Date and time of signature Date and time of signature 

Take a picture and/or keep a copy of this form. 

It contains important information about your rights and protections.

Self Elements Psychotherapy & Wellness

35 Beaverson Blvd. Suite 4D

Brick, NJ 08723

FEDERAL TAX ID: 27-3602820

GROUP NPI#: 1679183263 

More details about your estimate 

Client name: 

Date of Birth: _______________ Diagnosis: ___________________________________ 

Out-of-network provider(s) or facility name: Self Elements Psychotherapy & Wellness

Owned & operated by: Kerri Russell-Russo, LLC

The amount below is only an estimate; it isn’t an offer or contract for services. This estimate shows the full estimated costs of the items or services listed. It doesn’t include any information about what your health plan may cover. 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 and how much you may have to pay. 

GOOD FAITH ESTIMATE 

TABLE OF SERVICES AND FEES 

Service code 

(CPT Code) 

Description

Fee for Service (Number of Sessions Will Be Determined as We Progress)

90791 

Initial Diagnostic Evaluation 

$225

90832 

Psychotherapy, 16-37 minutes 

$120

90834 

Psychotherapy, 38-52 minutes 

$135

90837 

Psychotherapy  53-60 minutes 

$150

Family Psychotherapy without Patient Present, 50 minutes $155

Family Psychotherapy with Patient Present, 50 minutes $155

Your Therapist Requires a 24-Hour Cancelation Fee $75

Total Estimate: This Good Faith Estimate explains your therapist’s rate for each service provided. Your therapist 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 

diagnosis(es)/presenting clinical concerns.

Please note that Place of Service (in office vs. telemental health) is not delineated above since the charges are identical.