Updated September 7, 2025

Mulberry Therapeutic Services
2680 E Main St, Ste 227
Plainfield, IN 46168-2830
Niki Dula, MSW, LCSW – (765) 787-1196

As a provider of mental health services, I want to ensure that you understand your rights and financial responsibilities when receiving care. The No Surprises Act provides protections against unexpected medical bills for out-of-network care.

Mulberry Therapeutic Services is an out-of-network outpatient practice and is not in-network with any insurance plans as of May 2025. Since my practice is not in-network with any insurance plans, this notice is designed to help you understand your rights and avoid surprises when it comes to billing.

I do not bill for any services outside of the agreed-upon services as outlined in the practice policies and informed consent documents. As a client of Mulberry Therapeutic Services, you are directly responsible for the cost of services. While I do not accept insurance directly, many insurance companies may reimburse you for out-of-network services. If you would like to use insurance benefits for out-of-network coverage, you are responsible for submitting claims to your insurance company for reimbursement. If you have any questions about how to do this, I can help you with the necessary paperwork and documentation.

What is the No Surprises Act?

The No Surprises Act is a federal law designed to protect individuals from receiving unexpected medical bills for services that are not covered by their insurance network. It applies to situations where you receive out-of-network care from a provider, such as myself, who is not part of your insurance company’s network.

What Does This Mean for You?

You have the right to:

  • Receive a Good Faith Estimate of expected charges before receiving medical services
  • Protection from surprise billing for emergency services
  • Protection from surprise billing when receiving care from out-of-network providers at in-network facilities
  • Choose your provider for non-emergency services Good Faith Estimates

Good Faith Estimates

When You’ll Receive an Estimate

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

  • Don’t have insurance, or
  • Choose not to use your insurance, or
  • Receive care from a provider not covered by your insurance plan

Timeline

  • For scheduled services: You’ll receive your estimate at least 1 business day before your appointment (3 business days for services scheduled at least 10 business days in advance)
  • For unscheduled services: You’ll receive your estimate no later than 3 business days after scheduling

What’s Included

Your Good Faith Estimate will include:

  • Expected charges for medical services from Mulberry Therapeutic Services
  • Expected charges from other providers involved in your care (when applicable)
  • A patient-friendly explanation of the estimate

Protection from Surprise Bills

Emergency Services

  • You cannot be billed more than in-network cost-sharing amounts for emergency services, even if you are treated by an out-of-network provider or at an out-of-network facility.
  • You cannot be balance billed for emergency services
  • You don’t need prior authorization for emergency services

Out-of-Network Providers at In-Network Facilities

When you receive non-emergency services at an in-network facility, you’re protected from surprise bills from:

  • Out-of-network doctors
  • Other healthcare providers you didn’t choose
  • Services you couldn’t reasonably choose (like anesthesiology, radiology, or laboratory services.

Additional Information

  • Visit cms.gov/nosurprises or call 1-800-985-3059 for more information about your rights under Federal law.
  • If you believe an entity is not complying with the Federal Independent Dispute Resolution process, or you want to report a violation of the protections of the No Surprises Act, then you may contact the No Surprises Help Desk at 1-800-985-3059 to submit a question or complaint. 
  • If you think the protections have not been applied correctly, you can file an appeal with your insurance company or request external review of the company’s decision.
  • You also can file a complaint with the federal Department of Health and Human Services.

If you have any questions about this notice or anything else related to billing and payments, feel free to contact me directly. I am here to help make your experience as clear and stress-free as possible.

Thank you for choosing to work with me. I look forward to our work together.

For emergencies, always call 911 or go to your nearest emergency room.