Good Faith Estimate
You are entitled to receive a "Good Faith Estimate" of what the charges could be for psychotherapy services provided to you. While it is not possible for a psychotherapist to know, in advance, how many psychotherapy sessions may be necessary or appropriate for a given person, this form provides an estimate of the cost of services provided. Your total cost of services will depend upon the number of psychotherapy sessions you attend, you individual circumstances, and the type and amount of services that are provided to you.
There may be additional items or services that I may recommend as part of your care that must be scheduled or requested separately and are not reflected in this good faith estimate. This estimate is not a contract and does not obligate you to obtain any services from the provider listed, nor does it include any services rendered to you that are not identified here.
You have the right to initiate a dispute resolution process if the actual amount charged to you substantially exceeds the estimated charges stated in your Good Faith Estimate (which means $400 or more beyond the estimated charges).
For questions or more information about your right to a Good Faith Estimate or the dispute process, please visit http://www.cms.gov/nosurprises/consumers or call 1-800-985-3059. The initiation of the patient-provider dispute resolution process will not adversely affect the quality of services furnished to you.
Details of the Estimate
Initial Evaluation (90791) and Psychotherapy sessions (90834 or 90837)
Expected Cost:
The fee for a 50 minute psychotherapy visit (in person or via telehealth) is $225. Most clients will attend one psychotherapy visit per week, but the frequency of psychotherapy visits that are appropriate for your case may be more or less frequent that once per week, depending on your needs. Based upon the fee of $225 per visit, if you attend one psychotherapy visit per week, your estimated charge would be $900 for 4 visits provided over the course of one month; $1800 for 8 visits provided over the course of two months; $2700 for 12 visits over the course of three months. If you attend therapy for a longer period, you total estimated charges will increase according to the number of visits and the length of treatment.
Disclaimer:
You may contact the contact listed above if billed charges are higher than the Good Faith Estimate. You can request an update to the bill to match the Good Faith Estimate, ask to negotiate the bill, or ask if there is financial assistance available.
You may also start a dispute resolution process with the U.S. Department of Health and Human Services (HHS). If you choose to use the dispute resolution process, you must start the dispute process within 120 calendar days (about 4 months) of the date on the original bill.
There is a $25 fee to use the dispute process. If the agency reviewing your dispute agrees with you, you will have to pay the price on this Good Faith Estimate. If the agency disagrees with you and agrees with the health care provider or facility, you will have to pay the higher amount.
To learn more and get a form to start the process, go to:
www.cms.gov/nosurprises or call CMS at 1-800-985-3059.
For questions or more information about your right to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprises or call CMS at 1-800-985-3059 .
This Good Faith Estimate is not a contract. It does not obligate you to accept the services listed above.
This Good Faith Estimate is not intended to serve as a recommendation for treatment nor a prediction that you may need to attend a specified number of psychotherapy visits. The number of visits that are appropriate in your case, and the estimated cost for those services, depends on your needs and what you agree to in consultation with your therapist. You are entitled to disagree with any recommendations made to you concerning your treatment and you may discontinue treatment at any time.
You are encouraged to speak to your provider at any time about any questions that you may have regarding your treatment plan or the information provided to you in this Good Faith Estimate.