Good Faith Estimate
Notice of Your Rights Under the No Surprises Act
Effective January 1, 2022, the No Surprises Act protects healthcare consumers who are uninsured or choose not to use their insurance. Under this law, you are entitled to receive a Good Faith Estimate (GFE) outlining the expected costs of non-emergency medical items and services before care begins.
Out-of-Network Provider Notice
Please note that The Purple Tree LLC (TPT LLC) is not in-network with most health insurance plans. As a result, services provided by TPT LLC will typically be considered out-of-network, and your out-of-pocket costs may be higher than if you received care from an in-network provider.
You are not required to receive services from an out-of-network provider. You have the option to seek care from an in-network provider, which may reduce your costs.
Good Faith Estimate
In compliance with federal law, TPT LLC will provide you with a Good Faith Estimate of expected charges prior to the start of services. While the exact scope and duration of treatment may vary, we aim to offer a clear estimate of your anticipated financial responsibility.
Please note that this estimate may be revised over time based on changes in your care plan.
Additional Fees That May Apply
In some cases, you may also be billed for the following services:
Late cancellations or missed appointments
Requests for medical records
Completion of documentation (e.g., summary letters, forms)
Coordination of care or consultation with other providers
Questions or Concerns?
If you have any questions about this notice or your Good Faith Estimate, please reach out to us:
The Purple Tree LLC 📞 Phone: (614) 551-5715 📧 Email: info@purpletreetherapy.com
For more information about your rights under the No Surprises Act, visit www.cms.gov/nosurprises or contact the U.S. Department of Health and Human Services.
By proceeding with care at The Purple Tree LLC, you acknowledge and agree to receive out-of-network services and understand that this may result in higher costs.