The No Surprises Act 2022
The No Surprises Act provides federal protections against unexpected healthcare bills. The Act requires medical and other healthcare providers to give good faith estimates of the costs of services to prevent surprise costs, particularly when consumers are accessing out-of-network care. See below for a document disclosing your rights and protections against surprise healthcare bills.
| No Surprises Act Disclosure |
Forms for new adult clients.
Please complete the following forms and bring them along with your insurance card to your intake appointment.
| Consent Form for Adult Clients |
| Adult Intake Form |
| Consent to Use and Disclose PHI |
| Patient Financial Responsibility Form |
| Privacy Policies |
| Employee Assistance Program Form (for clients using EAP benefits) |
Forms for new child clients.
Please complete the following forms and bring them along with your insurance card to your intake appointment.
| Parent Consent Form for Child Clients |
| Assent Form for Adolescents (to be completed by adolescents aged 13-17) |
| Child History Form (to be completed by parent) |
| History Form (to be completed by adolescents aged 13-17) |
| Consent to Use/Disclose PHI |
| Patient Financial Responsibility Form |
| Privacy Policies |
| Employee Assistance Program Form (for clients using EAP benefits) |