GOOD FAITH ESTIMATE

Tax Id: 85-1170431

NPI #: 1619745585

Under the No Surprises Act (H.R. 133), you are entitled to receive this “Good Faith Estimate” of the charges for psychotherapy services provided to you by an out-of-network provider.

Under Section 2799B-6 of the Public Health Service Act, out-of-network healthcare providers and healthcare facilities are required to inform individuals upon request or at the time of scheduling healthcare items and services for out-of-network services, a “Good Faith Estimate” of expected charges for the year.

You have the right to receive a “Good Faith Estimate” explaining how much your care could cost over the year.

Under the law, healthcare providers need to give patients who don’t have insurance or who are using out-of-network benefits an estimate of the bill for services.

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 or office visits.

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.

If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill.

Hope Therapy Community Counseling Center is out-of-network for all insurance plans. If you are seeing an associate or licensed therapist and have PPO health insurance, we will electronically submit claims to your insurance as a courtesy. Until your out-of-network deductible is met, you will be responsible for the therapist’s total minimum cash fee, as listed on the fee schedule. Once your deductible is met and we receive the first payment, we will adjust the payment you pay at each session to account for the anticipated insurance payment. Once your insurance accepts the claim, we will see the allowed amount; this varies from insurance to insurance, and should this be less than the therapist’s cash fee, you will still be required to pay the minimum cash fee. At some point, if we charge you less than the therapist’s fee because we anticipate a payment from your insurance, you will be responsible for the therapist’s minimum cash fee should your insurance decline to pay or your insurance is no longer in effect. It is your responsibility to update us should you have a change to your insurance coverage.

Services to be provided: Psychotherapy (90791, 90834, 90837, 90846, 90846, or 90853)

Diagnosis to be treated: Mental, Emotional, Behavioral, Relational, Stress Management, Anger Management, or Trauma Recovery Diagnosis as applicable to each client.

While a psychotherapist can’t know, in advance, how many psychotherapy sessions may be necessary or appropriate for a given person, this form estimates the cost of services provided.  Your total cost of services will depend upon the number of psychotherapy sessions you attend, your circumstances, and the type and amount of services provided.  This estimate is not a contract and does not obligate you to obtain any services from the provider(s) listed, nor does it include any services rendered to you not identified here.

This Good Faith Estimate is not intended to serve as a recommendation for treatment or a prediction that you may need to attend a specified number of psychotherapy visits.  The number of appropriate visits and the estimated cost for those services depends on your needs and what you agree to in consultation with your therapist.  You are entitled to disagree with any recommendations concerning your treatment, and you may discontinue treatment at any time.