No Surprises Act/Good Faith Estimate
You are entitled to receive this Good Faith Estimate of your potential charges 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, your individual circumstances, and the type and amount of services that are provided to you. This estimate is not a contract and does not obligate you to obtain any services from the provider(s) listed, nor does it include any services rendered to you not identified here. This good faith estimate is valid for 12 months.
This Good Faith Estimate is not intended to serve as a recommendation for treatment or 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 concerning your treatment, and you may discontinue treatment at any time.
The fee for a 45-minute psychotherapy visit (in person or via telehealth) is $175. Most clients will attend one psychotherapy visit per week, but the frequency of psychotherapy visits that are appropriate in your case may be more or less than once per week, depending upon your needs or desires. You have a right to initiate a dispute resolution process with U.S. Department of Health and Human Services (HHS) 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). If you choose to utilize this dispute option, you must submit your claim within 120 calendar days from the date of your first bill. There is a $25 fee to utilize the HHS dispute process. If the agency reviewing your claims agrees with you, you must pay the price of the good faith estimate. If the agency disagrees with you and agrees with your healthcare provider, you will be required to pay the total amount.
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. Please visit www.cms.gov/nosurprises for more information or to start your dispute claim.
Make sure to save a copy or picture of your Good Faith Estimate and the bill.