About the Good Faith Estimate
Pursuant to the newly-adopted “No Surprises Act” of 2022 (HR133, Title 45 Section 149.610), I am required to provide all current and prospective clients with a “Good Faith Estimate” (GFE) of the charges for services to be provided to you over the course of your therapy for a 12 month period beginning at the date of your first session. If the fee for sessions is increased before 12 months is complete the 12 month period will begin again with the new fee. You will be given at least two months notice before the fee is increased.
Please note that it is not possible for any mental health care provider to know in advance the exact nature of treatment or the number and frequency sessions that may be necessary for a given person or situation.
This GFE is not a contract and does not obligate you to obtain any services from me. The GFE is not a recommendation or prediction of the treatment you may need or the number or frequency sessions you will need, which we will mutually agree to in the course of therapy. You are entitled to disagree with any recommendations made to you concerning your treatment and you may discontinue treatment at any time.
This Estimate covers one or more of the following therapy services:
- Individual Psychotherapy (CPT90834, CPT90832, CPT90837)
- Family Psychotherapy (CPT90847)
- Family Psychotherapy without Client Present (CPT90846)
- Consultation, Parent sessions or Additional Services Provided
Estimate of Fees: Standard Rate
My Standard Rate for Online Therapy (phone or video conference) or In-Person Therapy is currently $180 per 50-minute session for individuals, couples or families. This per-session fee covers all psychotherapsy diagnosis. Most clients will attend one therapy sesson per week, but the frequency might vary depending upon your needs. Based on these fees, the following are maximum charges which would be incurred for my services during the current calendar year.
Number of Weeks
in Therapy |
Total Fees if
1 Session per Week
Idividual or Couple
|
Total Fees if
2 Sessions per Week
Indidual or Couples |
Total Fees if
3 Sessions per Week
Indidual or Couple |
| 12 |
$2,160 |
$4,320 |
$6,408 |
| 24 |
$4,320 |
$8,640 |
$12,960 |
| 48 |
$8,640 |
$17,280 |
$25,920 |
Estimate of Fees: Non-Standard Rate
In some circumstances my Standard Rate may not apply in which case the above table cannot be used. However, you can easily cacluate the maximum charges incurred during the current calendar year as shown below:
Rate ($) X Weeks in Therapy X Sessions per Week = Maximum Charges ($)
- Rate is the per-sesson fee you are being charged, and will be shown on the Consent to Treament Form you signed at the beginning of therapy.
- Weeks in Therapy is an estimate of number of weeks in the current calendar year you will be receiveing therapy.
- Sessions per Week is the number of times per week you will be receiving Therapy (normally 1 time per week).
Incidental Fees
In addition, during the course of your therapy, it may be required that I consult with other professionals, or family members, write letters, read emails or documents, research therapy or other professional services. My Standard Rate applies for these services ($180 per 50 minutes).
Your Rights
You have a right to dispute my bill if the actual amount charged to you substantially exceeds the estimated charges above ($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 me at any time to let me know the billed charges are higher than this Good Faith Estimate and ask me to update the bill to match the Good Faith Estimate. 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 disputed 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 bill up to the amount shown 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 me at any time about any questions you may have regarding your treatment plan or bill, or the information provided to you in this Good Faith Estimate.
By completing this form and signing below you are acknowledging receipt of this Good Faith Estimate and that you understand what it says. If you have any questions, please contact me directly.