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GOOD FAITH ESTIMATE

All self-pay clients have the right to a "Good Faith Estimate". The Good Faith Estimate shows the costs of items and services that are reasonably expected for your health care needs for an item or service. 

 

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 using insurance coverage or not seeking to file a claim with their insurance provider a “Good Faith Estimate” of expected charges.

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. 

 

If you are billed for more than this Good Faith Estimate, you have the right to dispute the bill. 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 practice 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. 

 

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. 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.

This estimate is not a contract. You are not obligated to receive services at this practice or by this provider. Our office can provide you alternative referrals at your request.

Below is a schedule of fees for our most commonly used services:

90791: Initial Diagnostic Evaluation  $200

 

90846 or 90847: Family Therapy  $175

 

90837: Individual Therapy  $150