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NO SURPRISES ACT

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. 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 review all the fees with 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 print, sign, and date the consent document below before your next appointment and return the signed document before the appointment. You can email the completed form to admin@alapocascollaborativecare.com. You can also have the document sent to you through your client portal by messaging your clinician and asking them to send it.

 

If you have any questions please reach out to our billing department at 302-295-1088 ext.706.

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All information is confidential

Response emails will be coming from admin@alapocascollaborativecare.com, if you don't see a response in 48 hours pease check your spam folder or reach out to the email directly

Thanks for submitting! We will respond in 24 to 48 business hours.

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Please be sure to check your spam folder if you do not receive any emails after 48 business hours.

Contact us to book an appointment or for more information.

2 Mill Road, Suite 106, Wilmington, DE 19806   |   admin@alapocascollaborativecare.com

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