Forms

Below are a few of the forms Full Heart Therapy, LLC uses.

Before we meet for your initial session, you will be sent forms to complete through the Client Portal. We briefly review all appropriate forms in your first session.

And while filling out forms can be tedious, they are necessary. Many forms are government requirements that assist you in being aware of your rights. Others inform you about our working relationship and help me understand what you are going through. Your feedback about the process is always welcome.

Notice of Privacy Practices

The Notice of Privacy Practices informs you of your privacy and security rights as a client. This is according to Health Insurance Portability and Accountability Act of 1996 (HIPAA). HIPAA is United States legislation requiring data privacy and security provisions for safeguarding your medical information.

Notice of Privacy Practices

Good Faith Estimate

You have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost.

Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services.

  • You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees.
  • Make sure your health care provider gives you a Good Faith Estimate in writing at least 1 business day before your medical service or item. You can also ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule an item or service.
  • If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill.
  • Make sure to save a copy or picture of your Good Faith Estimate. For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises or call 800-985-3059.

Insurance Questionnaire/Confirmation of Benefits Form

This form can assist you in asking your Insurance Provider questions about seeking reimbursement of services with an Out-of-Network Provider. It can also assist you in better understanding your insurance policy and benefits. Therefore, it can help you make a more informed decision in choosing to work with me.

Insurance Questionnaire/Confirmation of Benefits