Surprise Billing Protection Notice

As of January 1, 2022, patients are entitled to notice, when your provider or facility isn’t in your health plan’s network, explaining the estimated cost of services, and what you may owe if you agree to be treated by this provider or facility.

If you and I have agreed not to use your health insurance but continue to meet, please provide your acknowledgment and consent using the online form. (see below). A PDF copy of the completed form will be emailed to you at the email address you provide in the form.

Please review the terms, then click the Consent box and the Send button to accept.
(I can send you a blank hard copy by mail or email or fax if you prefer.)


Surprise Billing Protection Notice

The purpose of this document is to let you know about your protections from unexpected medical bills. It also asks whether you would like to give up those protections and pay more for out-of-network care.

IMPORTANT: You aren’t required to sign this form and shouldn’t sign it if you didn’t have a choice of health care provider when you received care. You can choose to get care from a provider or facility in your health plan’s network, which may cost you less.

If you’d like assistance with this document, ask your provider or a patient advocate. Take a picture and/or keep a copy of this form for your records.


You’re getting this notice because this provider isn’t in your health plan’s network. This means the provider doesn’t have an agreement with your plan. Getting care from this provider or facility could cost you more. If your plan covers the service you’re getting, federal law protects you from higher bills:
  • When you get emergency care from out-of-network providers and facilities, or
  • When an out-of-network provider treats you at an in-network hospital or ambulatory surgical center without your knowledge or consent.
Ask your health care provider or patient advocate if you need help knowing if these protections apply to you. If you sign this form, you may pay more because:
  • You are giving up your protections under the law.
  • You may owe the full costs billed for items and services received.
  • Your health plan might not count any of the amount you pay towards your deductible and out-of-pocket limit. Contact your health plan for more information.
You shouldn’t sign this form if you didn’t have a choice of providers when receiving care. For example, if a doctor was assigned to you with no opportunity to make a change. Before deciding whether to sign this form, you can contact your health plan to find an in-network provider or facility. If there isn’t one, your health plan might work out an agreement with this provider or facility, or another one.

Estimate of what you could pay Out-of-network provider name: J. Gregory Turnbull, Psy.D. Cost estimate of what you may be asked to pay: $165.00 per 55-minute session.
  • Review your estimate.
  • Call your health plan. Your plan may have better information about how much you will be asked to pay. You also can ask about what’s covered under your plan and your provider options.
  • Questions about this notice and estimate? Ask Dr. Turnbull (808-398-8666).
Prior authorization or other care management limitations Except in an emergency, your health plan may require prior authorization (or other limitations) for certain items and services. This means you may need your plan’s approval that it will cover an item or service before you get them. If prior authorization is required, ask your health plan about what information is necessary to get coverage. Understanding your options If you have medical insurance, you may get the services described in this notice from providers who are in-network with your health plan. By signing, you give up your federal consumer protections and agree to pay more for out-of-network care. With your signature, you are saying that you agree to get the services from Dr. Turnbull. With your signature, you acknowledge that you are consenting of your own free will and are not being coerced or pressured. YouI also understand that:
  • You are giving up some consumer billing protections under federal law.
  • You may get a bill for the full charges for these items and services, or have to pay out-of-network cost-sharing under my health plan.
  • You were given this written notice explaining that your provider or facility isn’t in your health plan’s network, the estimated cost of services, and what you may owe if you agree to be treated by this provider or facility.
  • You got the notice either on paper or electronically. You fully and completely understand that some or all amounts you pay might not count toward your health plan’s deductible or out-of-pocket limit.
  • You can end this agreement by notifying the provider in writing before getting services.

IMPORTANT: You don’t have to sign this form. But if you don’t sign, this provider might not treat you. You can choose to get care from a provider or facility in your health plan’s network.

Hidden
MM slash DD slash YYYY
Patient's Name(Required)
Email(Required)
Consent(Required)