Michael Feeley, PhD

Licensed Psychologist

A Coach for Problem-Solving and Personal Development

You are here: Home -> Getting Started with Sessions -> Cover Letter for No Surprises Act

Cover Letter about the No Surprises Act

Date:

Dear

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.”

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 (attached). 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, attached you will find a fee schedule for the services typically offered by your therapist, and we will collaborate with you on a regular basis to determine how many sessions you may need.

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

Thank you very much.

Michael Feeley, PhD

You will need to sign this document electronically through my client portal. Your signature indicates you have read this cover letter.

The next document in this series is the No Surprises Act Explanatory Form and it can be found here.

If you have any questions about this form letter, please let me know.

Links to all three No Surprises Act forms:

The Cover Letter is here.

The Explantory Form is here.

The Consent Form is here.

Mike Feeley