Shannon Clark, PhD

Shannon Clark, PhD

Mailing Address: 7750 Clayton Rd. Suite 312, St. Louis, MO, 6311 

(314) 866-3957, shannon@shannonclarkphd.com,

THE NO SURPRISES ACT STANDARD NOTICE AND CONSENT DOCUMENTS 

SURPRISE BILLING PROTECTION FORM

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This form will be available for you to sign at the onset of treatment.

The purpose of this statement is to let you know about your protections from unexpected medical bills. It also asks whether you would like to give up those protections and pay more for out-of-network care.

You’re getting this notice because this provider or facility isn’t in your health plan’s network. This means the provider or facility doesn’t have an agreement with your plan.

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Getting care from this provider or facility could cost you more.

If your plan covers the item or service you’re getting, federal law protects you from higher bills:
• When you get emergency care from out-of-network providers and facilities, or
• When an out-of-network provider treats you at an in-network hospital or ambulatory surgical center without your knowledge or consent.

Ask your health care provider or patient advocate if you need help knowing if these protections apply to you.

If you sign this form, you may pay more because:
• You are giving up your protections under the law.
• You may owe the full costs billed for items and services received.
• 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.

You shouldn’t sign this form if you didn’t have a choice of providers when receiving care. For example, if a doctor was assigned to you with no opportunity to make a change.

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, your health plan might work out an agreement with this provider or facility, or another one.

See the next page for your cost estimate.

Estimate of what you could pay

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Out-of-network provider(s) or facility name: Shannon Clark, PhD
Total cost estimate of what you may be asked to pay: It is your ethical right to determine your goals for treatment and how long you would like to remain in therapy unless you are pursuing mandatory treatment. Please see the breakdown of possible fees on page four.
► Review your detailed estimate. See page four for a cost estimate for each item or service.
► Call your health plan. Your plan may have better information about how much of these services are reimbursable.
► Questions about this notice and estimate? Call Shannon Clark at (314) 866-3957 or email at shannon@shannonclarkphd.com.
► Questions about your rights? Contact:

Missouri Committee of Psychologists
3605 Missouri Boulevard
P.O. Box 1335
Jefferson City, MO 65102-1335
573.751.0099 Telephone
573.526.0661 Fax
800.735.2966 TTY
800.735.2466 Voice Relay
scop@pr.mo.gov
https://pr.mo.gov/psychologists.asp

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OR

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Utah Dept. of Commerce, Division of Occupational and Professional Licensing
(801) 530-6628
(866) 275-3675 Toll-Free in Utah
b3@utah.gov

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Prior authorization or other care management limitations:
Except in an emergency, your health plan may require prior authorization (or other limitations) for certain items and services. This means you may need your plan’s approval that it will cover an item or service before you get them. If prior authorization is required, ask your health plan about what information is necessary to get coverage.]

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More information about your rights and protections:
Visit https://www.cms.gov/files/document/model-disclosure-notice-patient-protections-against-surprise-billing-providers-facilities-health.pdf for more information about your rights under federal law.