-Who This Applies To:
  - Any patient who receives a covered service from an out-of-network provider at an in-network facility.
  - Any patient who receives emergency services, or services at facilities in which the provider is out-of-network, regardless of setting.

- What Is Considered a Covered Service:
  - Services that would normally be covered under your health plan.
  - Services performed by a provider who would be considered out-of-network for that plan if the patient were to obtain services outside of the facility’s network.

- Provider and Facility Information:
  - Tiffany Empowers, LLC
  - PO Box 6807 Augusta, GA 30916
  - Georgia and South Carolina

- How We Determine Billed Charges:
  - The standard charge for a given service.
  - The negotiated rate (if any) with your health plan.
  - The estimated patient responsibility after any plan benefits, discounts, or other reductions.
  - Any applicable patient cost-sharing, including copayments, coinsurance, or deductible amounts.

- What You Might Be Charged For:
  - Fees for therapy sessions, assessments, and other covered services.
  - Any balance billing that may occur if your provider is out-of-network.
  - Ancillary services (e.g., interpretation, testing) performed in conjunction with covered services.

- Estimated Surprise Billing Information:
  - You may receive a bill that reflects the difference between our charged amount and your insurer’s negotiated rate or an out-of-network charge.
  - We will provide an estimate of expected charges for a given service upon request or when a service is scheduled.

- How to Get an Estimate:
  - Call 762-221-1734 or email tiffany@tiffanyempowers.me for a personalized estimate for a specific date of service or service type.
  - Provide the following information to help us prepare an accurate estimate: your plan name, member ID, date of service, services requested, and the provider you will see.

- Dispute Resolution Options:
  - If you believe a bill is incorrect or you receive an unexpected balance, you can request a formal review.
  - We will review the billed charges, compare them to the negotiated rates, and provide a written explanation of any differences.
  - If needed, you can pursue independent dispute resolution through your plan or applicable regulatory processes in your state.

- Access to Records:
  - You have the right to request copies of your itemized bills and any related documentation.
  - For copies of records, contact us at 762-221-1734 or tiffany@tiffanyempowers.me.

- Complaints and Appeals:
  - If you have concerns about billing or claim denials, please contact us at 762-221-1734 or tiffany@tiffanyempowers.me.
  - You may also file a complaint with your state insurance department or relevant regulatory authority if you believe standards have not been met.

- Important Contact Information:
  - Billing Inquiries: 762-221-1734, tiffany@tiffanyempowers.me
  - State Insurance Department (for complaints): Georgia Department of Insurance / South Carolina Department of Insurance (contact details on their websites)

- Privacy and Confidentiality:
  - All information related to your billing and medical care remains confidential in accordance with HIPAA and applicable state laws.

- Updates to This Notice:
  - We may update this NSA notice to reflect changes in laws, affiliations, or billing practices. The most current version will be available on our website and at our front desk, and we will notify you of material changes as required by law.

- How This Notice Helps You:
  - Informs you of potential charges from out-of-network providers at in-network facilities.
  - Provides clear steps to obtain estimates and to challenge or appeal charges.
  - Supports transparency in billing to reduce surprise bills and ensure you understand your financial responsibilities.

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