Good Faith Estimate

Good Faith Estimate
Note: "Good Faith Estimate" (GFE) of expected charges for services provided pursuant to the No Surprises Act. This federal act was instituted to avoid balance billing and surprise billing to recipients of healthcare services using out of network or self pay medical services. This document is a required effort to be in compliance with such regulations.
Client Name

First NameLast Name
Street Address: *
Phone:   Area Code*   Phone Number*
DOB:   Date of Birth*
Email:   Email*
Date of Good Faith Estimate:   Today's date*
Office Locations:
- 27551 Cashford Circle #102, Wesley Chapel, FL 33544
- 18703 North Dale Mabry Lutz 33548
- Virtual Office
Services and respective codes:

(90791) biopsychosocial

(90837) individual counseling

(90847/90846) family with and without identified patient

*30-minute parent check-ins are billed at 50% of the clinician’s standard 53-minute rate.
I understand that all counseling services will be rendered at one of the above locations.
Therapist Name

First NameLast Name
Client's Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
DX CODE
I confirm to have received a copy via email or hard copy of the “Good Faith Estimate”.
Initials
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example@example.com
Should be Empty: