Legal

Dogwood Counseling & Wellness, LLC

10824 SE Oak ST #216

Milwaukie, OR 97222

Phone: 503-479-8695

CASH Pay Agreement

Cash Payment Agreement Date of Agreement: ___________

Name: __________

Person Responsible for Payment: _______________

Session Amount (50 minutes): $185

This is to acknowledge the agreement between Person Responsible for Payment and Dogwood

Counseling & Wellness, LLC to accept private pay as payment for services rendered. The amount

listed above is for therapy services only and does not include costs for reports, copies of records,

etc, they will be billed at the fee scheduled rates. Payments for services are due at the time the

service is rendered unless otherwise agreed up and documented in writing within this document.

Failure to pay in accordance with this agreement can result in immediately suspension or

termination of services. Any change to this original agreement must be made in writing on a new

agreement form.

No Surprise Act

No Surprise Act Effective January 1, 2022 Congress passed the No Surprise Act (NSA) as part of

the Consolidated Appropriations Act of 2021. The NSA is designed to protect patients from

surprise bills at out-of-network facilities or for out-of-network providers at in-network facilities,

holding them liable only for in-network cost-sharing amounts. The NSA also enables uninsured

patients to receive a Good Faith Estimate of the cost of care. Surprise billing occurs when clients

receive care from out-of-network providers without their knowledge. Surprise billing results in

higher costs for medical services that would have been cheaper if rendered by providers inside

the patients’ health plan network. NSA is intended to cut down on surprise costs and ban out-of-

network charges without advance notice (providing clients plain-language consumer notice).

Consumer Notice: It is a requirement that out-of-network providers provide all potential clients

with notice that they are outside of the client’s health plan network. All potential clients may

waive paying out-of-network prices for non-emergency services so long as they consent.

Good Faith Estimate: You have the right to receive a “Good Faith Estimate” explaining how

much your medical care (in this case, specifically mental health counseling services) will cost.

Under the law, healthcare providers are required to provide a Good Faith Estimate to out-of-

network/cash pay clients when they seek services. Providers are required to:

-Provide a Good Faith Estimate to an uninsured (or self-pay) individual: Within 1 business day

after scheduling (this timeline applies when the primary item or service is scheduled at least 3

business days before the day the client or patient would receive it) or no later than 3 business

days after scheduling (this timeline applies when the primary item or service is scheduled at least

10 business days before the client or patient would receive it), depending on scheduling; or

Within 3 business days after an uninsured (or self-pay) consumer requests a Good Faith Estimate.

-Include in the Good Faith Estimate an itemized list of each item or service, grouped by each

provider or facility offering care. Each item or service must share specific details and the

expected charge;

- Provide a paper or electronic copy of the Good Faith Estimate, even if the provider also

provides the Good Faith Estimate information to the individual over the phone or verbally in-

person;

-Provide the Good Faith Estimate using clear and understandable language;

If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the

bill;

You may request that I provide this notice to you in paper or electronic format;

The form will clearly state I am an out-of-network provider and provide an estimate of the cost of

my services (which I will have calculated in good faith). You are never required to give up your

protections from surprise billing. You also are not required to get out-of-network care. You can

choose a provider or facility in your plan’s network.

Lastly, there is a requirement which states that out-of-network providers must notify health plans

when they provide a client service, and they must certify that they have met the required notice

and consent requirements. I will keep these records for a minimum of seven years.

Complaints If you think you have been wrongly billed or are uncertain whether the No Surprises

Act applies to you or if you have any additional questions you may call Lauren Pillster, LPC at

503-479-8695 or send an email to laurenpillster@gmail.com. You may also contact: The Oregon

Board of Licensed Professional Counselors and Therapists: (503) 378-5499 or

lpct.board@mhra.oregon.gov; The U.S. Centers for Medicare & Medicaid Services (CMS) at

1-800-MEDICARE (1-800-633-4227) or visit https://www.cms.gov/nosurprises for more

information about your rights under federal law.

This is necessary because a time commitment is made to you and is held exclusively for you. If

you are late for a session, you may lose some of that session time or be billed for the full session

as insurance companies have rules for how much time a client must be in session in order for the

insurance company to pay for the session. If you are 15 minutes late, I will consider it a no-show

session (unless I have heard from you and we agreed on something different) and charged the

$185 cancellation fee.