Your Rights and Protections Against Surprise Medical Bills

(OMB Control Number: 0938-1401)

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.

Provider Status:

Creekside Counseling & Wellness is an out-of-network provider. This means the therapists are not contracted as part of your health plan.

Consultation Calls Prior to Scheduling:

All clients are responsible for calling to determine his/her out-of network benefits. All clients are offered a consultation call prior to scheduling. Fees for services will be verbally communicated to you during this call. Client will then be invited to set up a client portal to receive paperwork for the initial appointment and throughout your care.

What is “balance billing” (sometimes called “surprise billing”)?

When you see a doctor or other health care provider, you may owe certain out-of-pocket costs, such as a copayment, coinsurance, and/or a deductible. You may have other costs or have to pay the entire bill if you see a provider or visit a health care facility that isn’t in your health plan’s network.

“Out-of-network” describes providers and facilities that haven’t signed a contract with your health plan. Out-of-network providers may be permitted to bill you for the difference between what your plan agreed to pay and the full amount charged for a service. This is called “balance billing.” This amount is likely more than in-network costs for the same service and might not count toward your annual out-of-pocket limit.

“Surprise billing” is an unexpected balance bill. This can happen when you can’t control who is involved in your care – like when you have an emergency or when you schedule a visit at an in-network facility but are unexpectedly treated by an out-of-network provider.

Out-of-network providers can’t balance bill you unless you give written consent and give up your protections.

You’re never required to give up your protection from balance billing. You also aren’t required to get care out-of-network. You can choose a provider or facility in your plan’s network.

Super Billing:

You may request a super bill outlining the services you received and cost to submit to your insurance plan in order to access any out-of-network benefits available to you. Only fully licensed therapists can provide a super bill. Your therapist will disclose to you during the consult call whether or not they are able to provide this to you. This information is also part of the Good Faith Estimate Notice and Consent.

For questions or more information about your right to a Good Faith Estimate, visit or call Bonnie Barclay, LCSW, owner of Creekside Counseling & Wellness at (865) 325-9604 or email at [email protected].