Surprise Billing Protection Form

Standard Notice and Consent Under the No Surprises Act
(OMB Control Number: 0938-1401)

Your Rights and Protections Against Surprise Medical Bills

You’re receiving this notice because you are receiving services through Maternal Wellness Center of Nebraska and we want to ensure you understand your rights under federal law regarding out-of-network billing and surprise medical charges.

Even if your provider is currently in-network with your insurance, your benefits may change at any time due to employer plan changes, annual plan resets, or insurer contracting decisions. These circumstances may cause your provider to become out-of-network without advance notice.

For that reason, we encourage you to review the Good Faith Estimate table below. This estimate outlines typical charges so you can make informed decisions about your care, regardless of network status.

When Federal Protections Apply

Federal law protects you from surprise bills when:

  • You receive emergency services from an out-of-network provider or facility

  • You receive care from an out-of-network provider at an in-network facility without your knowledge or consent

However, if you choose to work with an out-of-network provider and sign this consent voluntarily, you may be billed directly for the services you receive.

What It Means If You Sign This Form

By signing this form, you acknowledge that:

  • You agree to pay higher costs for services provided by an out-of-network clinician

  • Your health plan may not apply payments to your deductible or out-of-pocket maximum

  • You may be responsible for the full billed amount

  • You are choosing this option freely, without pressure or coercion

Do Not Sign This Form If:

  • You did not have a choice of provider

  • You were assigned a provider without an opportunity to choose

Before signing, you may contact your insurance plan to ask about in-network alternatives or to request that an out-of-network agreement be negotiated.

Estimate of Services and Charges

Your therapist will work with you to determine the number and frequency of sessions that best meet your clinical needs. The fee schedule below reflects the standard rates charged at Maternal Wellness Center of Nebraska (Verdure Counseling LLC).

Good Faith Estimate of Services and Fees

Note: Fees are identical for in-person and telehealth sessions.

The number of sessions will be collaboratively determined based on treatment needs and progress.

Acknowledgment and Consent

By signing below, you confirm:

  • I understand I am voluntarily waiving my consumer protections under the No Surprises Act.

  • I have received a Good Faith Estimate for services.

  • I understand I may be billed for services at Maternal Wellness Center of Nebraska (Verdure Counseling LLC) that may not be covered by my insurance.

  • I acknowledge that my provider has discussed this information with me and I had the opportunity to ask questions.

You are not required to sign this form.
However, if you choose not to sign, your provider may be unable to continue treatment under an out-of-network arrangement.