Appointment Information                             Forms

Currently all appointments are over telehealth-video, or phone. Here is the video link: 
                       https://doxy.me/kerstinnp
​

---

Insurance

In-Network Insurance Plans in California:

• Aetna
• Cigna​​
• ​Medicare (Northern California Region)
• Anthem

​*Please note, I am not in-network with any medicaid or Medi-Cal plans and due to state laws cannot see patients with this insurance. ​

---

Fees

​Insurance  works when insurance companies contract with providers to reimburse all or part of the fees; contracted fees vary by insurance company. When paying out of pocket on the date of service the fees are: 
​
Fees:

• ​​Psychiatric Evaluation (first appointment)   $350
• Follow-up Appointments  (20-50 minutes)   $250
• No show or late cancellation fee  (24 hr)       $125

• Ketamine fees are on the Ketamine webpage

GOOD  FAITH  ESTIMATE
Under Section 2799B-6 of the Public Health Service Act, health care providers and health care facilities are required to inform individuals who are not enrolled in a health plan or coverage, a Federal health care program, or not seeking to file a claim with their plan or coverage of their ability, upon request or at the time of scheduling health care items and services, to receive a "Good Faith Estimate" of expected charges.

You have the right to receive a "Good Faith Estimate" explaining how much your medical care will cost. 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 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.
• You can also ask your health care 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.  

For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises.

• New Patient Forms: Complete these forms for the first appointment .

• Telehealth Consent Form: Complete this form for the first telehealth appointment. 
• Ketamine Consent form: Complete this from if you are starting treatment with Ketamine. 
• Release of Information Form: Only complete if needed.  Complete this form to share records or information with people involved in your care.
• ​HIPAA Notice of Privacy Practices 

---

Disability Forms

I am not able to determine if someone is disabled for medical leave, short term or long term, or complete any type of disability or off work/school forms.

Gilroy Office

8339 CHURCH STREET,  SUITE 114,  GILROY, CA 95020
Phone 408-767-2337   Fax 415-376-4572
Info@gilroymentalhealth.com
​Gilroymentalhealth.com