Good Faith Estimate

THE NO SURPRISES ACT AND GOOD FAITH ESTIMATE

HOW DOES IT AFFECT ME? WHY AM I BEING ASKED TO SIGN THIS?

As of January 1, 2022, all healthcare providers are required to provide estimates for the costs of your care. The Good Faith Estimate (GFE) shows the cost of items and services that are reasonably expected for your healthcare needs and treatment. This will be provided by this office upon scheduling and/or as requested. This Good Faith Estimate does not include unexpected costs that could arise during treatment.

HOW DOES THIS AFFECT BILLING AND PAYMENT POLICIES AT CHLOE CERINO NUTRITION, LLC?

The law protects you from surprise billing and "unexpected surprise charges". Chloe Cerino Nutrition, LLC does not send clients a bill. You will pay for your sessions as a charge on the day of your session (see Financial Agreement form for more information).

WHAT IS THE ESTIMATE? DO I OWE THIS AMOUNT?

Under provisions of this law, we are required to provide you with an estimate of your healthcare costs. You are entitled to receive this “Good Faith Estimate” of what the charges could be for nutrition services provided to you. While it is not possible for a registered dietitian to know in advance how many sessions may be necessary or appropriate for a given person, this form provides an estimate of the cost of services provided. Your total cost of services will depend upon the number of nutrition therapy sessions you attend, your individual circumstances, and the type and amount of services that are provided to you.

This Good Faith Estimate is not intended to serve as a recommendation for treatment or a prediction that you may need to attend a specified number of sessions with your dietitian. The number of visits that are appropriate in your case, and the estimated cost for those services will ultimately depend on your needs and what you agree to in consultation with your dietitian. You are entitled to disagree with any recommendations made to you concerning your treatment and you may discontinue treatment at any time. This estimate is not a contract and does not obligate you to obtain any services from the provider(s) listed, nor does it include any services rendered to you that are not identified here. We ultimately value the importance of self-determination and the therapeutic relationship. It is important that you understand your right to choose your provider based on your unique needs, the provider's specialization, and the right fit.

DIAGNOSIS

The No Surprises Act and Good Faith Estimate ask that we provide a diagnosis on this form. At Chloe Cerino Nutrition, LLC, we do not typically diagnose clients unless we believe a specific diagnosis to be accurate after careful consideration, assessment, and consultation with the client. We are ethically obligated to only diagnose after a thorough evaluation, assessment, and discussion with you and/or your team. We reserve the right to defer diagnosis until we can properly assess your case, conduct an appropriate evaluation, and discuss treatment planning with you and your team. Therefore, the current diagnosis for the purpose of this document is not identified. Please note that as registered dietitians, we are unable to diagnose certain conditions that we commonly work with including eating disorders and gastrointestinal syndromes and diseases. If you wish to receive a diagnosis for these concerns, you must visit a medical professional qualified to diagnose. Please contact us if you have any questions about receiving a diagnosis. 

CPT CODES

CPT codes (Current Procedural Terminology) are used to identify the professional services provided and to report those services in a way that can be universally understood by institutions, private and government payers, researchers, and other interested parties. Basically, this is a number that identifies the type of service received. Your treatment may include sessions that are coded by one or more of the CPT codes listed at the bottom of this form. 

PROVIDERS 

Chloe Cerino Nutrition, LLC provides nutrition services by registered dietitians. Our providers are listed below with their corresponding National Provider Identifier (NPI) and state licensure. You will be assigned a primary dietitian. Additionally, we may utilize meal support and recommend family sessions. Family sessions may be with one of our providers or someone we collaborate with on a regular basis. The practice tax identification number (EIN) is listed at the top of the page. Providers at Chloe Cerino Nutrition, LLC with their corresponding NPI and licensure information are listed below.

LOCATION OF SERVICES

Chloe Cerino Nutrition, LLC is located at 326 West Main Street, Suite 209, Milford, CT 06460. The providers listed conduct both in-person and virtual sessions. The estimate does not change based on your session being at the office or via telehealth.

EXPECTED FREQUENCY AND LENGTH OF TREATMENT

We recognize that each client has a unique treatment journey. Factors affecting your length of treatment may include: your presenting problem, history of presenting problem, stated goals for treatment, challenges and life circumstances, availability to schedule sessions, your support system, age at problem onset, presence of commonly occurring conditions we see in our clients, and others. Our standard practice is to create a treatment plan with client input after the initial session (or after we have time to develop treatment goals) and revise/update on an ongoing basis based on the client’s progress. Therefore, we are providing this estimate based on the timeframe we use for treatment planning.

Chloe Cerino Nutrition, LLC believes the therapeutic relationship to be paramount. We regard your autonomy, right to self-determination, and choice to receive treatment where you will most benefit.

DATE OF GOOD FAITH ESTIMATE 

The date of this GFE is the date in which you receive it through our portal or via email.

UNDERSTANDING YOUR GOOD FAITH ESTIMATE (GFE)

The following is a list of CPT codes that may be used. The fee for each session type is noted below.

Example Scenario 1). You see one provider from the list of providers on this form for weekly 30-minute follow-up sessions. Your monthly cost will be approximately $520.00. This assumes four weekly sessions per month. 

Example Scenario 2). You see one provider from the list of providers on this form for weekly 45-minute follow-up sessions and weekly meal supports. Your monthly cost will be approximately $1820.00. This assumes four weekly sessions per month of each type. 

Please note that these Example Scenarios are for demonstration purposes only and are not an estimate or recommendation for your specific needs, nor are they the only possible care scenarios. The GFE is based on your estimated healthcare costs while receiving care at Chloe Cerino Nutrition, LLC with one or more of the providers listed on this form.

THE CPT CODES WE COMMONLY USE

This cost estimate is true regardless of the location (in-office or telehealth). You can determine your estimated healthcare costs by multiplying the session fee X the number of sessions that you anticipate seeing your provider. Additionally, you and your provider will discuss this as you review the treatment plan and goals, and will continue to review, revise, and update your plan as clinically indicated. 

NOTE: This estimate does not include healthcare cost associated with:

GFE: DIAGNOSIS

The following are common diagnoses used with our clients. If you would like a diagnosis added to your GFE, please let a clinician know. NOTE: this list is not exhaustive, and we do utilize other diagnostic codes after consultation with you and your team.

GOOD FAITH ESTIMATE HEALTHCARE ITEMS AND SERVICES

Good Faith Estimate (GFE)

You will be asked to sign this form. Your signature represents that you received this form, had the opportunity to discuss with your provider, understand your rights and that you understand how this relates to our practice.

This Good Faith Estimate shows the costs of items and services that are reasonably expected for your health care needs for an item or service. The estimate is based on information known at the time the estimate was created. Actual items, services,
or charges may differ from the Good Faith Estimate. There may be additional items or services we recommend as part of the course of care that must be scheduled or requested separately and are not reflected in this Good Faith Estimate. The Good Faith Estimate does not include any unknown or unexpected costs that may arise during treatment. You could be charged more if complications or special circumstances occur. If this happens, federal law allows you to dispute (appeal) the bill.

If you are billed for $400 or more than the total amount of expected charges listed on this Good Faith Estimate, you have the right to dispute the bill.

You may contact us to let us know the billed charges are higher than the Good Faith Estimate. You can ask them to update the bill to match the Good Faith Estimate, ask to negotiate the bill, or ask if there is financial assistance available. You may also start a dispute resolution process with the U.S. Department of Health and Human Services (HHS). If you choose to use the dispute resolution process, you must start the dispute process within 120 calendar days (about 4 months) of the date on the original bill. The initiation of the dispute resolution process will not adversely affect the quality of services furnished to you.

There is a $25 fee to use the dispute process. If the agency reviewing your dispute agrees with you, you will have to pay the price on this Good Faith Estimate, less the $25 fee. If the agency disagrees with you and agrees with the health care provider or facility, you will have to pay the higher amount.

To learn more and get a form to start the process, go to www.cms.gov/nosurprises or call 1-800-985-3059. For questions or more information about your right to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprises or call 1-800-985-3059.

Keep a copy of this Good Faith Estimate in a safe place or take pictures of it.

If you would like your diagnosis updated on this GFE, you must let your clinician know.