Good Faith Estimate

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 enrolled in a plan or coverage or a Federal health care program, or not seeking to file a claim with their plan or coverage both orally and in writing of their ability, upon request or at the time of scheduling health care items and services, to receive a "Good Faith Estimate" of expected charges.

Note: The PHSA and the GFE does not apply currently to any clients who are using insurance benefits, including Out of Network Benefits (seeking reimbursement from your insurance companies).

 

 

Common Services at Mindful Counseling: 

• 90791: Diagnostic Interview 
• 90834: 45 minute psychotherapy session 
• 90847: Family/ Couple psychotherapy session
• No Show/ Late Cancellation Fee: Your therapist requires at least 24-hour notice of cancellation. ($50)  

Common Diagnosis Code at Mindful Counseling:

• F32.9: Major Depressive Disorder, Unspecified
• F41.1: Generalized Anxiety Disorder
• F43.1: Post-Traumatic Stress Disorder
• F43.20: Adjustment Disorder, Unspecified
• Z65.9 Problem related to unspecified psychosocial circumstances
• Z62.820: Parent/Child Relational Conflict 
• Z63.0: Relationship Distress with Spouse or Initmate Partner

At Mindful Counseling, we recognize that every person's journey is unique. How long and how often you need to engage in therapy can be influenced by several factors.

• Your schedule 
• Therapist availability 
• Ongoing challenges
• Life events
• Personal finances

Where services will be Received

• 4619 Greene Ave NW, Suite C, Albuquerque, NM 87114
• 4004 Carlisle Blvd NE, Suite Q Albuqueruque, NM 87107
• Online via Telehealth 

 

The following is an estimated cost of receiving therapy services through a Mindful Counseling LLC provider. This estimate is based on you receiving weekly sessions for the duration for one year. This estimate accounts for a total of 50 weeks in a year, accounting for vacations, holidays, cancellations, sickness, etc.  

Facility Name: Mindful Counseling LLC

NPI: 1831420876

Tax ID: 27-1316602

Phone #: (505) 899-9328

Email: admin@mindfulcounseling.org 

Service: 90791 (Diagnostic Interview)

Schedule: First appointment (1)

Diagnosis: Z65.9

Session Fee: $95

Total Cost: $95

 

Service: 90834 (45 min.)	Service: 90847 (Fam/Couple)
Schedule: Weekly (50 wks)	Schedule: Weekly (50 wks)
Diagnosis:TBD	Diagnosis:TBD
Session Fee: $95	Session Fee: $95
Total Cost for Year: $4,750	Total Cost for Year: $4,750

Disclaimer & Your Rights

The information provided in this Good Faith Estimate is only an estimate, actual items, services, or charges may differ from the Good Faith Estimate.

This Good Faith Estimate shows the costs of items and services that are reasonably expected for your healthcare needs for an item or service. 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 cost 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.

You as a patient have the right to initiate a patient-provider dispute resolution process if the actual billed charges substantially exceed the expected charges included in the good faith

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.

The good faith estimate is not a contract and does not require any individual to obtain the items or services from any of the providers or facilities identified in the good faith estimate.

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 haveto 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.  

For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises or call HHS at 1-800-985-3059. 

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.

By signing below, I understand that my provider is providing a "good faith estimate" of the cost associate with my care.

I understand that if I have health insurance, and the services I am receiving from this Provider are a covered benefit under my health insurance plan, that I may receive services at an "in- network" provider/facility at a reduced rate.

Take pictures of this Good Faith Estimate or request a copy for records by emailing your request to admin@mindfulcounsleing.org.