New Client Forms
ALL NEW CLIENTS: Please wait for Dr. Dunn to send you a personalized email with forms to complete and return. You do NOT need to complete the below authorization to release information unless I am speaking with another person regarding confidential information.
** PLEASE MAKE SURE TO VERIFY WITH YOUR INSURANCE CARRIER THAT THEY COVER TELEHEALTH SERVICES.
** PLEASE MAKE SURE TO VERIFY WITH YOUR INSURANCE CARRIER THAT THEY COVER TELEHEALTH SERVICES.
Authorization to release/exchange information*
(*only complete if you would like to authorize me to release or exchange information about your care to someone other than you)
| authorization_to_release_information.pdf |
Fees/ Rate
Please call me to ask about current rates for services. Payment is being accepted via check, cash, or credit card. Effective Oct 15, 2021, I am an Out of Network provider with all insurances except Medicare. I am happy to provide statements that you may submit to insurance for "out of network" benefits. P{ease be sure to verify telehealth benefits.
For Clients Who Do Not Have Insurance, or Will Not Be Using Insurance/ OON Benefits:
Prior to treatment, I can provide a "Good Faith Estimate" in compliance with the "No Surprises Act."
Notice from CMS: "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"
For Clients Who Do Not Have Insurance, or Will Not Be Using Insurance/ OON Benefits:
Prior to treatment, I can provide a "Good Faith Estimate" in compliance with the "No Surprises Act."
Notice from CMS: "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"
Notice of Privacy Practices
Please click here for a notice of privacy practices related to HIPPA
| privacy_notice-hippa.docx |
