The purpose of this notice is to inform you of the No Surprise Act under section 27988B2(d)of the Public Health Service Act (PHS Act) and how consumers are protected from unexpected medical bills related to out-of-network service providers. This document describes your protections against unexpected medical bills. It also asks if you’d like to give up those protections and pay more for out-of-network care.

IMPORTANT: You aren’t required to sign this form and shouldn’t sign it if you didn’t have a choice of health care provider before scheduling care. You can choose to get care from a provider or facility in your health plan’s network, which may cost you less. If you’d like assistance with this document, ask your provider or a patient advocate. Take a picture and/or keep a copy of this form for your records.

You are getting this notice because New York Integrative Psychiatry is not in your health plan’s network and is considered out-of-network. This means the provider or facility doesn’t have an agreement with your plan to provide services. Getting care from this provider or facility will likely cost you more. If your plan covers the item or service you’re getting, federal law protects you from higher bills when:

• You’re getting emergency care from an out-of-network provider or facility, or

• An out-of-network provider is treating you at an in-network hospital or ambulatory surgical center without getting your consent to receive a higher bill.

Ask your health care provider or patient advocate if you’re not sure if these protections apply to you.

If you sign this form, be aware that you may pay more because:

• You are giving up your legal protections from higher bills.

• You may owe the full costs billed for the items and services you get.

• Your health plan might not count any of the amount you pay towards your deductible and out-of-pocket limit.

Contact your health plan for more information. Before deciding whether to sign this form, you can contact your health plan to find an in-network provider or facility. If there isn’t one, you can explore your out of network benefits with your insurance plan to determine the percentage of reimbursement you are entitled to receive in the event you utilize an out of network provider.