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  • Home
  • About
  • Services
    • Psychotherapy
    • Consultation
    • Training
  • Writing
    • Blog
    • Other Publications
  • Forms
  • No Surprises Act
    • A Note About the No Surprises Act
    • Your Rights and Protections
    • Good Faith Estimates
  • Contact
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No Surprises Act

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Rights and Protections Against Surprises
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Federal Rights and Protections Notice 
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January 2022

Dear Clients and Prospective Clients:

In compliance with the No Surprises Act that goes into effect January 1, 2022, all healthcare providers are required to notify clients of their Federal rights and protections against “surprise billing.”

It may seem that this does not apply to you.  The Act was designed to protect people from surprises when they received emergency services at hospitals or other healthcare facilities.  However, it is being applied broadly to all healthcare providers.

This Act requires that we notify you of your federally protected rights to receive a notification when services are rendered by an out-of-network provider, if a client is uninsured, or if a client elects not to use their insurance.

Additionally, we are required to provide you with a Good Faith Estimate of the cost of services. It is difficult to determine the true length of treatment for mental health care, and each client has a right to decide how long they would like to participate in mental health care. Therefore, you will be provided a fee schedule for the services typically offered, and we will collaborate on a regular basis to determine how many sessions will best help you achieve your goals. 

A sample Good Faith Estimate is available to download at the top of this page.

It is a Federal requirement that we have each client sign a form to begin/resume treatment. When you receive this form, please sign, date, and return it before your first or next appointment.  If you have any questions, please don’t hesitate to ask.

Thank you very much.

Warmly,

Jeff Levy, LCSW
Sing out. Be Free.

4507 N. Ravenswood, Suite 104  |  Chicago  |  IL  |  60640  |  1-773-490-2772
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