COUNSERLORS INTAKE
Each counselor at Vann Wellness Group has their own forms for their practice; the forms on this page are the generic forms that are used by most of the Counselors at this office. Please directly contact your counselor for the additional Intake forms that include the Counseling Agreement and Intake Questionnaire.
ARE YOU READY TO collaborate WITH US?
Lori Vann is a Licensed Professional Counselor Supervisor who is also an international speaker, media guest for news outlets around the world, and author of numerous books. For more information about her speaking services or to have her as a guest on your show, please go to www.LoriVann.com.
Under the No Surprises Act
Under Section 2799B-6 of the Public Health Service Act, health care providers and health care facilities are required to provide a good faith estimate of expected charges for items and services to individuals who are not enrolled in a plan or coverage or a Federal health care program, or not seeking to file a claim with their plan or coverage both orally and in writing, upon request or at the time of scheduling health care items and services. This form may be used by the health care providers to inform individuals who are not enrolled in a plan or coverage or a Federal health care program (uninsured individuals), or individuals who are enrolled but not seeking to file a claim with their plan or coverage (self-pay individuals) of the expected charges they may be billed for receiving certain health care items and services. A good faith estimate must be provided within 3 business days upon request. Information regarding scheduled items and services must be furnished within 1 business day of scheduling an item or service to be provided in 3 business days, and within 3 business days of scheduling an item or service to be provided in at least 10 business days.
Disclaimer
This Good Faith Estimate shows the costs of items and services that are reasonably expected for your health care needs for an item or service. The estimate is based on information known at the time the estimate was created. The Good Faith Estimate does not include any unknown or unexpected costs that may arise during treatment. You could be charged more if complications or special circumstances occur. If this happens, federal law allows you to dispute (appeal) the bill. If you are-billed for more than this Good Faith Estimate, you have the right to dispute the bill. You may contact the healthcare provider or facility listed to let them know the billed charges are higher than the Good Faith Estimate. You can ask them to update the bill to match the Good Faith Estimate, ask to negotiate the bill or ask if there is financial assistance available. You may also start a dispute resolution process with the U.S. Department of Health and Human Services (HHS). If you choose to use the dispute resolution process, you must start the dispute the process within 120 calendar days (about 4 months) of the date on the original bill. There is a $25 fee to use the dispute process. If the agency reviewing your dispute agrees with you, you will have to pay the price on this Good Faith Estimate. If the agency disagrees with you and agrees with the health care provider or facility, you will have to pay the higher amount.
To learn more and get a form to start the process, go to www.cms.gov/nosurprises.
For questions or more information about your right to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprises
