Our responsibility to you under the new law

In compliance with the No SurprisesAct that went 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 (forms are below). 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 find a fee schedule for the services typically offered by 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 these forms to begin/resume treatment. Please download, fill in, sign and date the forms and return the signed documents before your next appointment.

If you have any questions, please don’t hesitate to ask.

Barrington Behavioral Health & Wellness

The No Surprises Act

If you are an existing client, or new to the practice, please download the following forms, fill them in, and return them to Barrington Behavioral Health and Wellness prior to your next appointment.

These forms are Adobe “Fill-In” and may be completed using most popular PDF readers.

No Surprises Letter

Download this letter to learn our responsibilty to you under the No Surprises Act.

Good Faith Estimate

Brenda Danielson, Psy. D., LCP, works with adults across the lifespan with a specialty in women’s mental health, trauma, grief and loss, and co-occurring disorders. She is certified in several evidence-based therapies including CPT, CBT, CBT-I and ROSES. Call to make an appointment: 888-261-2178

Download this form for your reference and your therapist will discuss this with you.

Estimate Fee Schedule

Download this reference table of fees for service. Number of sessions TBD with your clinician.

Private Pay Contract

If you intend to pay “Out Of Pocket” (fee for service), download this form and complete it and remit it to BBHW prior to your next appointment.

If you are a new or existing client and have questions regarding the “No Surprises Act” as it applies to your treatment, you may contact us at Barrington Behavioral Health & Wellness.

Phone: 1-888-261-2178
Email: help@barringtonbhw.com

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