Good Faith Estimate
You have the right to receive a “Good faith Estimate” explaining how much your medical care will cost
Effective January 1, 2022, a ruling went into effect, called the "No Surprises Act". Under the law, health care providers need to give patients, who do not 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 healthcare provider gives you a Good Faith Estimate, in writing, at least 1 business day before your medical service or item. You can 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 received a bill that is at least $400.00 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) 368-1019.
If you would like me to coordinate care with another provider (for example, your psychiatrist, primary care physician, etc.), complete this form to authorize release of psychotherapy information:
- Authorization to Disclose Information Form
Note: To download Adobe Acrobat Reader for free, Click here.
Professional Disclosure Statement:
Professional Disclosure Statement
Meghan Smith, LPC, NCC
Meghan’s Place: Outpatient+ Eating Disorder Therapy
10700 SW Beaverton-Hillsdale Hwy Suite 696
Beaverton, Oregon
971-205-0408
Philosophy and Approach: My theoretical orientation approaches change from a behavioral approach. By drawing on cognitive-behavioral therapy and dialectical behavioral therapy through a wellness lens, a cohesive model of change emerges which emphasizes all client's capability of change if given the right tools. Negative behaviors or nonadaptive behaviors are merely a symptom of lack of healthy coping strategies and the inability to cope with circumstances in a healthy manner. All thoughts and behaviors can change to become more adaptive for the client's life and future goals.I also recognize the importance of emotional regulation and the need for client buy-in for treatment to be successful. My specific focus is directed towards individuals who struggle with body image issues, disordered eating patterns and food anxiety. I also use a collaborative model in my practice along with motivational interviewing techniques with sensitivity to client's individuality and cultural experience.
Formal Education and Training: I hold a master’s degree from Lewis and Clark College in Professional Mental Health Counseling. I also hold a certificate in eating disorder diagnosis and treatment from Lewis and Clark College. As a Licensee of the Oregon Board of Licensed Professional Counselors and Therapists, I am required to participate in continuing education, taking classes relevant to subjects relevant to the profession. I also do consult with other colleagues in the field on a monthly basis to discuss helpful treatment interventions and to ensure you are receiving the most helpful care. During these consults, your private information is protected.
Fees: I take a variety of insurance plans to help with payment with services. For a complete list of insurance companies that are in-network with me, please ask. Initial consultations are complimentary. Individual counseling sessions (55 minutes) are $145 per session. Additionally, I commit to providing lower fee sessions or pro bono sessions to 15% of my clients on an ongoing basis. Prior to the start of the first counseling session, all clients will be made aware of the financial obligations pertaining to therapy. Please cancel sessions at least 48 hours in advance to avoid being charged for a session.
As a client of an Oregon Licensed Professional Counselor, you have the following rights:
∗ To expect that a licensee has met the qualifications of training and experience required by state law;
∗ To examine public records maintained by the Board and to have the Board confirm credentials of a licensee;
∗ To obtain a copy of the Code of Ethics (Oregon Administrative Rules 833-100);
∗ To report complaints to the Board;
∗ To be informed of the cost of professional services before receiving the services;
∗ To be assured of privacy and confidentiality while receiving services as defined by rule or law, with the following exceptions: 1) Reporting suspected child abuse; 2) Reporting imminent danger to you or others; 3) Reporting information required in court proceedings or by your insurance company, or other relevant agencies; 4) Providing information concerning licensee case consultation or supervision; and 5) Defending claims brought by you against me;
∗ To be free from discrimination because of age, color, culture, disability, ethnicity, national origin, gender, race, religion, sexual orientation, marital status, or socioeconomic status.
You may contact the Board of Licensed Professional Counselors and Therapists at
3218 Pringle Rd SE, #120, Salem, OR 97302-6312 Telephone: (503) 378-5499
Email: [email protected] Website: www.oregon.gov/OBLPCT
For additional information about this licensee, consult the Board’s website.
What is “balance billing” (sometimes called “surprise billing”)?
When you see a doctor or other health care provider, you may owe certain out-of-pocket costs, such as a copayment, coinsurance, and/or a deductible. You may have other costs or have to pay the entire bill if you see a provider or visit a healthcare facility that isn’t in your health plan’s network.
“Out-of-network” describes providers and facilities that haven’t signed a contract with your health plan. Out-of-network providers may be permitted to bill you for the difference between what your plan agreed to pay and the full amount charged for a service. This is called “balance billing.” This amount is likely more than in-network costs for the same service and might not count toward your annual out-of-pocket limit.
“Surprise billing” is an unexpected balance bill. This can happen when you can’t control who is involved in your care - like when you have an emergency or when you schedule a visit at an in-network facility but are unexpectedly treated by an out-of-network provider.
You are protected from balance billing for:
Emergency services
If you have an emergency medical condition and get emergency services from an out-of-network provider or facility, the most the provider or facility may bill you is your plan’s in-network cost-sharing amount (such as copayments and coinsurance). You can’t be balance billed for these emergency services. This includes services you may get after you’re in stable condition, unless you give written consent and give up your protections not to be balanced billed for these post-stabilization services.
Certain services at an in-network hospital or ambulatory surgical center
When you get services from an in-network hospital or ambulatory surgical center, certain providers there may be out-of-network. In these cases, the most those providers may bill you is your plan’s in-network cost-sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services. These providers can’t balance bill you and may not ask you to give up your protections not to be balance billed.
If you get other services at these in-network facilities, out-of-network providers can’t balance bill you unless you give written consent and give up your protections.
You’re never required to give up your protection from balance billing. You also aren’t required to get care out-of-network. You can choose a provider or facility in your plan’s network.