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White Sheet


General Information

Please read on to learn more about the practice's payment policies, No Surprises Act Disclosure and Notice of Privacy Practices required by federal law.  Fees vary by type of service, session length, and are subject to change over time.  Any changes will be communicated to current clients.  This information does not take the place of a signed Informed Consent, Privacy Policy or Good Faith Estimate provided to clients at the start and during the course of treatment.  

Contact Amy Tesz to receive of copy of the Informed Consent, which includes detailed rates, or to discuss any questions about payment.

Forms of Payment

Cash, check, flexible health spending cards, and all major credit cards are accepted for payment.  Checks should be made payable to Amy Tesz, LMHC, ATR-BC.


Payment Consent

A Payment Consent form is required to be kept on file to be used to cover outstanding balances.  Debit or credit card information is encrypted, and your consent may be revoked by you in writing at any time (please see Payment Consent form for details). 



I am considered out-of-network for all insurance plans.  Payment is due in full at the time of session. 


Please be aware that each insurance plan’s coverage is different, and it is your responsibility to verify the specifics of your coverage.  Please contact your insurance company prior to initiating sessions to ask the following questions:

  • Do I have mental health benefits?

    • If so, what procedure (CPT) codes are covered? (The practice most often uses 90791, 90834, 90837, 90846, 90847.)

  • Do I have out of network coverage?

  • Do I have a deductible and has it been met?

  • How many sessions per year are covered?

  • What is the coverage amount per session?

  • Is approval from my primary care physician required?

  • Is prior authorization required?  If so, is there an authorization number that must be referenced?  How many sessions does the authorization cover?

  • How do I access the forms required to request a reimbursement for out of network services?


Out of Network Claims

If your insurance plan is a Preferred Provider Organization (PPO) plan, you may be able to request reimbursement for clinical services provided by me.  A detailed receipt (“superbill”) will be provided to you monthly, which you can submit to your insurance company for reimbursement if you so choose.  Please contact your insurance provider directly to learn about your plan’s policy for out of network claim submissions.  See below for more information about your rights under The No Surprises Act.


Outstanding Balances

Outstanding balances of 60 days or more will be charged 1.5% interest per month (18% APR).  You will be charged a $30 fee for checks returned for insufficient funds.  You agree that in the event your account is turned over to a collection agency or attorney due to non-payment, you will pay an additional 33.3% of the balance as reasonable collections fees (to be added to the balance at the time the account is place for collection) plus any court costs and attorney’s fees incurred in connection with the collection of your account. 



Effective January 1, 2022, the No Surprises Act, which Congress passed as part of the Consolidated Appropriations Act of 2021, is designed to protect patients from surprise bills for emergency services at out-of-network facilities or for out-of-network providers at in-network facilities, holding them liable only for in-network cost-sharing amounts. The No Surprises Act also enables uninsured patients to receive a good faith estimate of the cost of care.


Your Rights and Protections Against Surprise Medical Bills


When you get emergency care or get treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from surprise billing or balance billing.


What is “balance billing” (sometimes called “surprise billing”)?

When you see a doctor or other health care provider, you may owe certain out-of-pocket costs, such as a copayment, coinsurance, and/or a deductible. You may have other costs or have to pay the entire bill if you see a provider or visit a health care facility that isn’t in your health plan’s network. “Out-of-network” describes providers and facilities that haven’t signed a contract with your health plan. Out-of-network providers may be permitted to bill you for the difference between what your plan agreed to pay and the full amount charged for a service. This is called “balance billing.” This amount is likely more than in-network costs for the same service and might not count toward your annual out-of-pocket limit. “Surprise billing” is an unexpected balance bill. This can happen when you can’t control who is involved in your care—like when you have an emergency or when you schedule a visit at an in-network facility but are unexpectedly treated by an out-of-network provider.


You are protected from balance billing for:


Emergency services

If you have an emergency medical condition and get emergency services from an out-of-network provider or facility, the most the provider or facility may bill you is your plan’s in-network cost-sharing amount (such as copayments and coinsurance). You can’t be balance billed for these emergency services. This includes services you may get after you’re in stable condition, unless you give written consent and give up your protections not to be balanced billed for these post-stabilization services.


Additionally, Massachusetts protects patients from balance billing when patients receive (i) covered non-emergency services from an out-of-network provider when patients did not receive notice that the provider was out-of-network; (ii) covered medically necessary services from an out-of-network provider when such services are not available in-network,; (iii) covered medically necessary services from an out of network provider at an in-network facility, if patients did not have a reasonable opportunity to choose an in-network provider. These protections apply to patients with coverage through insurers licensed to transact accident or health insurance, a nonprofit hospital service corporation, a nonprofit medical service corporation, a health maintenance organization (“HMO”), and preferred provider organization (“PPO”). These protections only require patients to pay the amount required for in-network services.


Certain services at an in-network hospital or ambulatory surgical center

When you get services from an in-network hospital or ambulatory surgical center, certain providers there may be out-of-network. In these cases, the most those providers may bill you is your plan’s in-network cost-sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services. These providers can’t balance bill you and may not ask you to give up your protections not to be balance billed. If you get other services at these in-network facilities, out-of-network providers can’t balance bill you, unless you give written consent and give up your protections.


You’re never required to give up your protections from balance billing. You also aren’t required to get care out-of-network. You can choose a provider or facility in your plan’s network.


Additionally, Massachusetts also protects patients with coverage through a PPO from balance billing when patients receive emergency services and cannot reasonably reach a preferred provider. Additionally, Massachusetts protects patients with coverage through an HMO from balance billing when patients receive emergency services.


When balance billing isn’t allowed, you also have the following protections:

  • You are only responsible for paying your share of the cost (like the copayments, coinsurance, and deductibles that you would pay if the provider or facility was in-network). Your health plan will pay out-of-network providers and facilities directly.

  • Your health plan generally must:

    • Cover emergency services without requiring you to get approval for services in advance (prior authorization).

    • Cover emergency services by out-of-network providers.

    • Base what you owe the provider or facility (cost-sharing) on what it would pay an in-network provider or facility and show that amount in your explanation of benefits.

    • Count any amount you pay for emergency services or out-of-network services toward your deductible and out-of-pocket limit.


If you believe you’ve been wrongly billed, you may contact:

  • The U.S. Centers for Medicare & Medicaid Services (CMS) at 1-800-MEDICARE (1-800-633-4227) or visit for more information about your rights under federal law.

  • The Massachusetts Division of Insurance, Consumer Service Unit at 617-521-7794.


Good Faith Estimate

You have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost.


Under the law, healthcare providers need to give patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services.

  • You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes related costs like medical tests, prescription drugs, equipment and hospital fees.

  • Make sure your healthcare provider gives you a Good Faith Estimate in writing at least one business day before your medical service or item. You can also ask your healthcare provider, and any other provider you choose, for a Good Faith Estimate before you schedule an item or 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.

Get More Information

For questions or more information about your right to a Good Faith Estimate, visit or call 1-800-MEDICARE (1-800-633-4227).

No Surprises Act



No Surprises Act

Amy Tesz, LMHC, ATR-BC (the “Practice”) is committed to protecting your privacy. The Practice is required by federal law to maintain the privacy of Protected Health Information (“PHI”), which is information that identifies or could be used to identify you. The Practice is required to provide you with this Notice of Privacy Practices (this “Notice”), which explains the Practice's legal duties and privacy practices and your rights regarding PHI that we collect and maintain.

Your rights regarding PHI are explained below. To exercise these rights, please submit a written request to the Practice at the address noted below.

To inspect and copy PHI.

  • You can ask for an electronic or paper copy of PHI. The Practice may charge you a reasonable fee.

  • The Practice may deny your request if it believes the disclosure will endanger your life or another person's life. You may have a right to have this decision reviewed.

To amend PHI.

  • You can ask to correct PHI you believe is incorrect or incomplete. The Practice may require you to make your request in writing and provide a reason for the request.

  • The Practice may deny your request. The Practice will send a written explanation for the denial and allow you to submit a written statement of disagreement.

To request confidential communications.

  • You can ask the Practice to contact you in a specific way. The Practice will say “yes” to all reasonable requests.

To limit what is used or shared.

  • You can ask the Practice not to use or share PHI for treatment, payment, or business operations. The Practice is not required to agree if it would affect your care.

  • If you pay for a service or health care item out-of-pocket in full, you can ask the Practice not to share PHI with your health insurer.

  • You can ask for the Practice not to share your PHI with family members or friends by stating the specific restriction requested and to whom you want the restriction to apply.

To obtain a list of those with whom your PHI has been shared.

  • You can ask for a list, called an accounting, of the times your health information has been shared. You can receive one accounting every 12 months at no charge, but you may be charged a reasonable fee if you ask for one more frequently.

To receive a copy of this Notice.

  • You can ask for a paper copy of this Notice, even if you agreed to receive the Notice electronically.

To choose someone to act for you.

  • If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights.

To file a complaint if you feel your rights are violated.

  • You can file a complaint by contacting the Practice using the following information:

Amy Tesz, LMHC, ATR-BC

10 Muzzey Street, Suite 9

Lexington, MA 02421

(781) 541-8001

  • You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting

  • The Practice will not retaliate against you for filing a complaint.

To opt out of receiving fundraising communications.

  • The Practice may contact you for fundraising efforts, but you can ask not to be contacted again.



1. Routine Uses and Disclosures of PHI
The Practice is permitted under federal law to use and disclose PHI, without your written authorization, for certain routine uses and disclosures, such as those made for treatment, payment, and the operation of our business. The Practice typically uses or shares your health information in the following ways:

To treat you.

  • The Practice can use and share PHI with other professionals who are treating you.

  • Example: Your primary care doctor asks about your mental health treatment.

To run the health care operations.

  • The Practice can use and share PHI to run the business, improve your care, and contact you.

  • Example: The Practice uses PHI to send you appointment reminders if you choose.

To bill for your services.

  • The Practice can use and share PHI to bill and get payment from health plans or other entities.

  • Example: The Practice gives PHI to your health insurance plan so it will pay for your services.

2. Uses and Disclosures of PHI That May Be Made Without Your Authorization or Opportunity to Object
The Practice may use or disclose PHI without your authorization or an opportunity for you to object, including:

To help with public health and safety issues

  • Public health: To prevent the spread of disease, assist in product recalls, and report adverse reactions to medication.

  • Required by the Secretary of Health and Human Services: We may be required to disclose your PHI to the Secretary of Health and Human Services to investigate or determine our compliance with the requirements of the final rule on Standards for Privacy of Individually Identifiable Health Information.

  • Health oversight: For audits, investigations, and inspections by government agencies that oversee the health care system, government benefit programs, other government regulatory programs, and civil rights laws.

  • Serious threat to health or safety: To prevent a serious and imminent threat.

  • Abuse or Neglect: To report abuse, neglect, or domestic violence.

To comply with law, law enforcement, or other government requests

  • Required by law: If required by federal, state or local law.

  • Judicial and administrative proceedings: To respond to a court order, subpoena, or discovery request.

  • Law enforcement: For law locate and identify you or disclose information about a victim of a crime.

  • Specialized Government Functions: For military or national security concerns, including intelligence, protective services for heads of state, or your security clearance.

  • National security and intelligence activities: For intelligence, counterintelligence, protection of the President, other authorized persons or foreign heads of state, for purpose of determining your own security clearance and other national security activities authorized by law.

  • Workers' Compensation: To comply with workers' compensation laws or support claims.

To comply with other requests

  • Coroners and Funeral Directors: To perform their legally authorized duties.

  • Organ Donation: For organ donation or transplantation.

  • Research: For research that has been approved by an institutional review board.

  • Inmates: The Practice created or received your PHI in the course of providing care.

  • Business Associates: To organizations that perform functions, activities or services on our behalf.

3. Uses and Disclosures of PHI That May Be Made With Your Authorization or Opportunity to Object
Unless you object, the Practice may disclose PHI:

To your family, friends, or others if PHI directly relates to that person's involvement in your care.

If it is in your best interest because you are unable to state your preference.

4. Uses and Disclosures of PHI Based Upon Your Written Authorization
The Practice must obtain your written authorization to use and/or disclose PHI for the following purposes:

Marketing, sale of PHI, and psychotherapy notes.

You may revoke your authorization, at any time, by contacting the Practice in writing, using the information above. The Practice will not use or share PHI other than as described in Notice unless you give your permission in writing.


  • The Practice is required by law to maintain the privacy and security of PHI.

  • The Practice is required to abide by the terms of this Notice currently in effect. Where more stringent state or federal law governs PHI, the Practice will abide by the more stringent law.

  • The Practice reserves the right to amend Notice. All changes are applicable to PHI collected and maintained by the Practice. Should the Practice make changes, you may obtain a revised Notice by requesting a copy from the Practice, using the information above, or by viewing a copy on the website

  • The Practice will inform you if PHI is compromised in a breach.

This Notice is effective on July 1, 2023.

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