Good Faith Estimate Notice
The Federal “No Surprises Act” grants consumers the right to receive a “Good Faith Estimate” for the total expected cost of any non-emergency items or services. Under the law, health
care providers are required to give patients who don’t have insurance or who are not using insurance an estimate of the expected charges for treatment services. The act also requires healthcare providers to inform their patients of this right. You can ask your health care provider for a Good Faith Estimate before you schedule a service. If you receive a bill that is at least $400 more than your Good Faith Estimate you can dispute the bill. Make sure to save a copy or picture of your Good Faith Estimate. For questions of more information about your right to a Good Faith Estimate, visit www.cms.gov/no surprises.
West Los Angeles Psychiatrist and Therapist
Michelle G. Ashley, M.D.
Diplomate, American Board of Psychiatry and Neurology
Se Habla Espanol
12304 Santa Monica Blvd. Suite 212 Los Angeles, CA 90025
(310) 582-5223
Please print out, complete, and bring the forms to your initial evaluation.
Consent For Treatment Telemedicine Consent
Patient Information
HIPAA Notice Of Privacy Practices
Receipt and Acknowledgement of HIPAA Notice Of Privacy Practices
Consent To Release Information Credit Card Consent and Authorization
Content copyright 2010-2017. Michelle G. Ashley, M.D. All rights reserved.