No Surprises Act Notice

Monarch Therapy & Wellness LLC
Effective Date: September 20, 2026

At Monarch Therapy & Wellness LLC, we want you to understand how your therapy services will be billed and what you can expect to pay.

Monarch serves clients who use health insurance as well as clients who choose to pay privately. Your financial responsibility depends on whether you are using insurance to pay for your services.

If you choose to use health insurance, Monarch may submit claims to your health insurance plan when Monarch and your clinician participate with that plan.

Your insurance plan determines your coverage, deductible, copayment, coinsurance, allowed amount, and other applicable cost-sharing requirements. Monarch cannot guarantee that your insurance plan will cover a particular service or that a claim will be paid at a particular amount.

You are responsible for amounts determined by your insurance plan to be your responsibility, including applicable deductibles, copayments, coinsurance, and other patient responsibility.

Before beginning treatment, we encourage you to contact your insurance plan to confirm your behavioral-health benefits and whether your clinician is in-network.

An Explanation of Benefits (EOB) from your insurance company is not a bill. It explains how your insurance processed a claim and may show the amount your plan assigns to you as patient responsibility.

If you believe an insurance claim or patient balance has been processed incorrectly, please contact Monarch so we can review the account and, when appropriate, work with your insurance plan to address the issue.

If you do not have health insurance, or if you have insurance but choose not to use it for your Monarch services, you are considered an uninsured or self-pay individual for purposes of the federal Good Faith Estimate requirements.

For self-pay services, Monarch's standard private-pay rate is:

Individual, family, and other standard therapy sessions: $150 per session

Certain services or circumstances may have different charges. Any applicable charges will be communicated to you before services are provided whenever reasonably possible.

For example, EMDR services at Monarch are offered on a private-pay basis and are not billed through insurance.

Under the federal No Surprises Act, uninsured and self-pay individuals generally have the right to receive a Good Faith Estimate (GFE) of expected charges for scheduled health care services.

Monarch will provide a written Good Faith Estimate when required by federal law and will provide an estimate upon request.

A Good Faith Estimate is not a bill and is not a guarantee of the final amount you will owe. It is an estimate of charges that Monarch reasonably expects to provide based on the information available when the estimate is prepared.

For ongoing psychotherapy, the actual number and frequency of sessions may change based on your clinical needs, treatment plan, progress, scheduling, cancellations, or other circumstances. Services that were not reasonably expected when an estimate was prepared may therefore result in charges that were not included in the original estimate.

If you are uninsured or self-pay, Monarch will provide a Good Faith Estimate when required by federal law.

Generally:

• If services are scheduled at least 10 business days in advance, the estimate must be provided within 3 business days after scheduling.
• If services are scheduled 3–9 business days in advance, the estimate must be provided within 1 business day after scheduling.
• If you request an estimate before scheduling care, the estimate generally must be provided within 3 business days after your request.
• Services scheduled fewer than 3 business days in advance generally do not trigger the federal requirement to provide a GFE before that appointment.

Monarch may provide an estimate sooner whenever practical.

A Good Faith Estimate will identify the health care services reasonably expected to be provided and the associated expected charges.

Depending on the circumstances, the estimate may include information such as:

• The type of therapy service;
• Expected service/procedure code;
• Applicable diagnosis information when required or available;
• Expected number or quantity of services;
• Expected charge per service;
• Total expected charges from Monarch; and
• Relevant information or assumptions used to prepare the estimate.

Federal guidance requires the GFE to contain an itemized description of expected services and charges.

A Good Faith Estimate is based on information reasonably available when it is prepared.

For ongoing therapy, Monarch may initially estimate a course of care based on the information available at intake. The actual course of treatment may change as your clinician evaluates your needs and develops or modifies your treatment plan.

For example, an estimate might be based on weekly therapy for an anticipated period of time. If your clinician determines that a different frequency or duration is appropriate, the expected charges may change.

A new or revised estimate may therefore be appropriate when there is a significant change in the services reasonably expected to be provided.

If you are uninsured or self-pay and receive a bill from Monarch that is at least $400 more than the amount shown on your Good Faith Estimate, you may be eligible to use the federal Patient-Provider Dispute Resolution process.

Eligibility and other requirements apply, including requirements concerning the timing of the estimate and the bill.

If you believe you have received a bill that qualifies for this process, you may contact Monarch first to discuss the difference between the estimate and the bill.

You may also contact the federal No Surprises Help Desk at 1-800-985-3059 for information about your rights and the dispute process.

If you have insurance but choose to pay Monarch directly rather than submit claims to your insurance plan, you are considered self-pay for purposes of the Good Faith Estimate requirements.

Choosing to self-pay may be appropriate in some circumstances, including when a service is not covered by your insurance plan or when you prefer not to use your insurance.

Before choosing self-pay, you may wish to contact your insurance plan to understand your benefits and potential coverage.

If you have questions about:

• Your insurance benefits;
• Your expected copayment, coinsurance, or deductible;
• Monarch's private-pay rates;
• A Good Faith Estimate;
• A bill or patient balance; or
• How a service will be billed,

please contact Monarch Therapy & Wellness LLC before receiving services whenever possible.

Monarch is committed to providing clear information about expected charges and helping clients understand their financial responsibility.

Monarch Therapy & Wellness LLC
contact@monarchtherapywellness.com

Federal No Surprises Help Desk: 1-800-985-3059