In compliance with the “No Surprises Act” that went into effect January 1, 2022, all healthcare providers are required to notify clients of their Federal rights and protections against “surprise billing.” This Act requires that we notify you of your federally protected rights to receive a notification when services are rendered by an out-of-network provider, if a client is uninsured, or if a client elects not to use their insurance. Additionally, we are required to provide you with a “Good Faith Estimate” that works to show the cost of items and services that are reasonably expected for your mental health care
needs for an item of service.
The table below represents your “Good Faith Estimate” as it identifies what your financial costs would be per month and per year based on how frequently you attend sessions. Please know that you decide how often you would like to attend sessions and that it is normal for the frequency of meetings to ebb and flow based on what is going on in your life. Based on the individual nature of this process, no formal estimate is given specifically to you. Please reference this table as needed and let me know if you ever have any questions or concerns.
| 1 x Month | 2 x Month | 3 x Month | 4 x Month | |
Monthly Cost | $140 | $280 | $420 | $560 |
Yearly Cost | $1,680 | $3,360 | $5,040 | $6,720 |
Good Faith Estimate Disclaimers:
This Good Faith Estimate shows the costs of services that are reasonably expected for your health care. The estimate is based on information known at the time the estimate was created.
The Good Faith Estimate does not include any unknown or unexpected costs that may arise during treatment. You could be charged more if complications or special circumstances occur. If this happens, federal law allows you to dispute (appeal) the bill.
The Good Faith Estimate does not include services not provided by your provider that you may need and that your provider may recommend. For instance, the Good Faith Estimate does not include the cost of seeking medication for mental health.
The Good Faith Estimate is an estimate for services only and does not include other fees, such as fees for cancelling less than 24 hours in advance. These fees are outlined in the informed consent that is signed before the start of therapy services and that you have control over.
This Good Faith Estimate is not a contract and does not obligate you to receive the services listed nor does it obligate you to receive the services listed by this provider.
You have a 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).
You may contact the health care provider or facility listed to let them know the billed charges are higher than the Good Faith Estimate. You can ask them to update 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 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 800-985-3059.
You are encouraged to speak with your provider at any time about any questions you may have regarding your treatment plan, or the information provided to you in this Good Faith Estimate.