Good Faith Estimate

NOTICE

You have the right to receive a Good Faith Estimate explaining how much your medical (including mental health) care will cost

Under the law, health care providers need to give clients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services. Psychotherapy for mental and emotional health care is included under the medical umbrella.

• You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees.

• Make sure your health care provider gives you a Good Faith Estimate in writing at least 1 business day before your medical service or item. 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.

• Make sure to save a copy or picture of your Good Faith Estimate.

For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises or contact me via my secure contact form.

SAMPLE GOOD FAITH ESTIMATE

Pursuant to the No Surprises Act (HR133, Title 45 Section 149.610), this form is used to provide a current or prospective client with a Good Faith Estimate (GFE) of expected charges for services to be provided.

NOTE: The sample below does not contain any sample client information nor any sample or actual rates information. This is only to demonstrate what information would be provided to you. My actual form may look different from below.

Please visit my Rates, Hours & Info page for my current rates.

Client Name:

Client Date of Birth:

Client Address:

Client Phone #: (       )                         

Client Email:

Diagnosis Codes (if known):

Services Requested (Type and Codes): 

Provider Name

License #:

Provider Address:

Provider Phone #: (       )

Provider Tax ID# (if applicable):              

Provider NPI # (if applicable):

You are entitled to receive this 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 to be 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 that may be recommended during treatment to you that are not identified here.

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 made to you concerning your treatment and you may discontinue treatment at any time.

The fee for a __-minute psychotherapy visit via telehealth is $___.  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 on your goals.

Based on this per visit fee cited above, the following are expected charges of psychotherapy services:

Session fee = $Y_USD (See my Rates, Hours & Info page for current rates.)

1 week of service @1 session/week = 1x $Y_USD; @2 sessions/week = 2x $Y_USD

13 weeks of service @1 session/week = 13x $Y_USD; @2 sessions/week = 13x $Y_USD x 2

26 weeks of service @1 session/week = 26x $Y_USD; @2 sessions/week = 26x $Y_USD x 2

39 weeks of service @1 session/week = 39x $Y_USD; @2 sessions/week = 39x $Y_USD x 2

52 weeks of service @1 session/week = 52x $Y_USD; @2 sessions/week = 52x $Y_USD x 2

You have a right to dispute a bill if the actual amount charged to you substantially exceeds the estimated charges stated in your Good Faith Estimate. ‘Substantially exceeds’ means $400 or more beyond the estimated charges.

Initiating the dispute process will not adversely affect the quality of services rendered to you. 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, 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 HHS at (800) 368-1019.

Keep a copy of this Good Faith Estimate in a safe place or take pictures of it. You may need it if you are billed a higher 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.

Date of this Estimate _____________________________

TRANSPARENCY

You Got This Therapy has always provided transparency in billing practices by providing rates information on this website and in the informed consent/intake paperwork. Please see my Rates, Hours & Info page for more details. Additionally, rates are always discussed in our initial consultation call.

If you have questions or concerns about the Good Faith Estimate or No Surprises Act, please contact me.