Patient Rights

 
 

I. No Surprises Act - Disclosure Notice Regarding Patient Protections Against Surprise Billing

II. No Surprises Act - Letter to Clients :

Dear Client or Prospective Client: Please read this Good Faith document, complete the section below, then sign and date this document. Thank you in advance.

.******************************* GOOD-FAITH ESTIMATE **********************************

Provider:  Dr. R Berchick License/#:  PS 003869-L

Provider Address:  433 E. St. Rd., Warminster PA Provider Phone #: (215)  674-9445

Business Tax ID#:   45 - 5460131           NPI #:  128 5976 605   

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Patient Name: _________________________________________________________

Patient Address:________________________________________________________

Patient Phone #: (       ) ________________________________                        

Patient Email:________________________________________

Patient Diagnosis (if known/applicable):____________________

Services Requested:  Consultation 90871 one-and-a-half-hour interview. In addition, there will be self-report forms to be completed at home and then sent to me; COST:  $225.00  Individual psychotherapy 90837 fifty-five to a sixty-minute session; COST: $185.00. Fifty-five to a sixty-minute Couples Therapy Session; COST: $215.00. Forensic services; COST: $400.00 per hour. Other professional services rendered; COST: $185.00 per hour.

You are entitled to receive this “Good Faith Estimate” of what the charges could be for psychotherapy services provided to you. While it is not possible for a psychotherapist to know, in advance, how many psychotherapy sessions may be necessary or appropriate for a given person, this form provides an estimate of the cost of services offered. Your total cost of services will depend on the number of psychotherapy sessions you attend, your circumstances, and the type and amount of services provided. This estimate is not a contract and does not obligate you to obtain any psychological from Dr.Berchick, nor does it include any services rendered to you that are not identified here. 

This Good Faith Estimate is not intended to serve as a recommendation for treatment or a prediction that you may need to attend a specified number of psychotherapy visits. The number of visits in your case, and the estimated cost for those services, depending on your needs, will be discussed periodically and documented. You are entitled to disagree with any recommendations made to you concerning your treatment, and you may discontinue treatment at any time.

Again, the fee for the code 90871; for a 90-120 minute (in-person or via telehealth) is $225.00.  If you and I agree to work together after this Consult Session we would probably meet for one psychotherapy visit per week, but the frequency of psychotherapy visits that are appropriate in your case may be more or less than once per week, depending upon your needs.

If offered, the fee for code 90874 (55-60 minutes of psychotherapy) is $185.00 per visit; thus, if you attend one psychotherapy visit per week, your estimated charge would be $185.00. For two psychotherapy sessions provided over the course of one month is $370.00. For four visits provided over the course of one month, $740.00. For eight visits over two months, $1,480.00. For 12 visits over three months is $2,220. If you attend therapy for a more extended period, your total estimated charges will increase according to the number of visits and length of treatment.

 

Signature and Date of this Estimate _____________________________________________________________

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III. Bill of Rights

  • You can ask me to communicate with you in a particular way or at a certain place. For example, you can ask me to call you at home rather than at work to schedule or cancel an appointment. I will try my best to do as you ask.

  • You have the right to ask me to release your records to certain people involved in your care, such as family and friends, nonetheless, you have a right to limit what I share. While I don’t have to agree to your request, if I do agree, I will keep our agreement except if it is against the law, or in an emergency, or when the information is necessary to treat you.

  • You have the right to look at the health information I have about you, such as your medical and billing records. You can get a copy of these records, however as stated in my Service agreement, I may wish to review the chart with you prior to release.

  • You have the right to a copy of this notice. If I change this NPP, I will make a copy of the changes available in my waiting room and you can always get a copy of it from me.

  • You have the right to file a complaint if you believe your privacy rights have been violated. You can file a complaint with me and with the Secretary of the Department of Health and Human Services. All complaints must be in writing. Filing a complaint will not change the health care I provide to you in any way.

  • If there is a breach of your confidentiality, then I must inform you as well as Health and Human Services. A breach means that information has been released without authorization or without legal authority unless I (the covered entity) can show that there was a low risk that the PHI has been compromised because the unauthorized person did not view the PHI or it was de-identified.

  • If you are self-pay and do not submit receipts to insurance companies, then you may restrict the information sent to insurance companies

  • Most uses and disclosures of psychotherapy notes and of protected health information require that you must sign an authorization (release of information form) for releases unless it is for purposes already mentioned in this Privacy Notice (such as mandated reporting of child abuse, reporting of elder abuse, reporting of impaired drivers, etc).

  • You have a right to receive a copy of your Protected Health Information in an electronic format or (through a written authorization) designate a third party who may receive such information. As I do not use electronic records, we will need to discuss such a request.