Under Section 2799B-6 of the Public Health Service Act and its implementing regulations, health care providers, health care facilities, and providers of air ambulance services are required to provide a good faith estimate of expected charges for items and services to individuals who are not enrolled in a group health plan or group or individual health insurance coverage, or a Federal health care program, or a Federal Employees Health Benefits (FEHB) program health benefits plan (uninsured individuals) or not seeking to file a claim with their group health plan, health insurance coverage, or FEHB health benefits plan (self-pay individuals) in writing (and may also provide it orally, if an uninsured (or self-pay) individual request a good faith estimate in a method other than paper or electronically), upon request or at the time of scheduling health care items and services.

Beginning January 1, 2022, these No Surprises Act requirements will apply to items and services provided to most individuals enrolled in private or commercial health coverage, like: • Employment-based group health plans (both self-insured and fully insured) • Individual or group health coverage on or outside the Federal or State-based Exchanges • Federal Employee Health Benefit (FEHB) health plans • Non-federal governmental plans sponsored by state and local government employers • Certain church plans within IRS jurisdiction • Student health insurance coverage [as defined at 45 CFR 147.145]

If an individual does not have certain types of health insurance or does not plan to use that insurance to pay for health care items or services, they are eligible to receive a “good faith estimate” of what they may be charged, before they receive the item or service. • A new patient-provider dispute resolution (PPDR) process is available for uninsured (or self-pay) individuals who get a bill from a provider that is substantially in excess of the expected charges on the good faith estimate.

Disclaimer:

For this purpose, the Good Faith Estimate provides the cost of items and services that are reasonably expected for your mental health care needs.  The estimate is based on information known at the time the estimate was created, involving the client’s reason for seeking therapy.  The Good Faith Estimate does not include any unknown or unexpected costs that may arise during treatment. The Good Faith Estimate is only an estimate- Your provider may recommend additional services that are not reflected in this Good Faith Estimate, actual items/services charges may differ. You may be charged more if complications or special circumstances occur. Other potential items and/or services, including fees, may include but is not limited to no-show/late cancellation (fee (s), record requests, letter writing (s), legal fee (s)/court attendance (s), professional collaboration, and in-between session supports. These potential services and fees are further discussed in the Informed Consent documentation. Furthermore, if these items/services be initiated a new Good Faith Estimate will be provided. The Good Faith Estimate does obligate the client to obtain listed items or services.

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 provider (psychotherapist) to know, in advance, how many psychotherapy sessions may be necessary or appropriate for a given person upon the initiation of psychotherapy, this form provides an estimate of the cost of services provided based on 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 listed, nor does it include any services rendered to you that are not identified here.  

The fee for a typical 45-minute psychotherapy session (in-person or via telehealth) is $175 (CPT Code 90834 for in-person or CPT Code 90834-95 for telehealth). The projected future costs of therapy can be calculated by multiplying the session fee of $175 (for a 45-minute session) by the total number of sessions, which would result in an estimate of mental health sessions. The total estimate changes based on the type of service, item provided to the client.

When determining your total estimate, it is also imperative to take into consideration vacations, holidays, emergencies, and sick time. If you attend therapy for a shorter or longer period, your total estimated charges will decrease or increase according to the number of visits and length of treatment, and the type of service that is provided.

How long you need to engage in therapy (length of treatment) and how often you attend sessions will be influenced by many factors including our office hours, your life circumstances and/or possible challenges, your therapist availability, your finances, and your interest and commitment to treatment.

By signing, I give up my federal consumer protections and agree to pay more for out-of-network care.

With my signature, I acknowledge that I am consenting of my own free will and am not being coerced or pressured. I also understand that:

• I’m giving up some consumer billing protections under federal law.

• I may get a bill for the full charges for these items and services, or have to pay out-of-network cost-sharing under my health plan.

• I was given a written notice on [enter date of notice] explaining that my provider or facility isn’t in my health plan’s network, the estimated cost of services, and what I may owe if I agree to be treated by this provider or facility.

• I got the notice either on paper or electronically, consistent with my choice.

• I fully and completely understand that some or all amounts I pay might not count toward my health plan’s deductible or out-of-pocket limit.

• I can end this agreement by notifying the provider or facility in writing before getting services.

IMPORTANT: You don’t have to sign this form. But if you don’t sign, this provider or facility might not treat you. You can choose to get care from a provider or facility in your health plan’s network.

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