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Good Faith Estimate Under the No Surprises Act

Borici Counseling LLC charges a rate of $150 per psychotherapy session, unless otherwise discussed with client on a case by case basis. If you are in network with Blue Cross Blue Shield, Borici Counseling LLC will always encourage you to clarify with your network in regard to exact copayments and out of pocket expenses and or deductible amount to determine coverage.

A good faith estimate of charges is always available in writing upon request.

Throughout the course of your therapeutic relationship with Borici Counseling LLC you may receive services that are different from your initial plan, which may or may not be covered by your insurance company depending on changes in our billing practices, changes in your insurance coverage, or other factors. This disclosure ensures that you understand and agree that Borici Counseling LLC's fees are due whether or not your insurance covers a service, whether or not your insurance covers a service in an amount different from what was initially believed to be covered, or whether or not a service is defined, categorized, or billed in a manner that is different from a manner accepted by your insurance company. By signing on to treatment, you will sign a form in your intake paperwork. By doing so, you acknowledged that Borici Counseling LLC will not be an arbiter of disagreements between you and your insurance company and will not be held responsible for any unexpected or surprise actions taken by your insurance company, and you are responsible for the services you receive whether or not the insurance company pays for or covers services.

Disclaimer: 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 or call [HHS PHONE NUMBER]. For questions or more information about your right to a Good Faith Estimate or the dispute process, visit or call [HHS NUMBER].

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