GOOD FAITH ESTIMATE FOR HEALTH CARE SERVICES

(in compliance with Federal No Surprises Act of 2021)

The following is a Good Faith Estimate for psychotherapy with your therapist:

  • Type of service: individual or couples psychotherapy

  • Service code: 90834 (individual therapy) or 90847 (couples therapy)

  • Applicable diagnosis codes: if your therapist uses a diagnosis code, a typical example could be F43.2, Adjustment Disorder

  • Date(s) of service: recurring weekly

  • Estimated number of sessions: 15-50 sessions in a year

  • Individual therapy

    -Cost of sessions: $145-$195 per session

    -Estimated total cost: $2,000-$10,000*

  • Couples therapy

    -Cost of sessions: $175-$225 per session

    -Estimated total cost: $2,700-$12,000*

*Note:estimated costs are valid for 12 months from the date of this Good Faith Estimate, which is the same date as your signed consent form.

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.

Lastly, keep in mind, therapy is an investment in yourself. For many people, it can save them money–through greater productivity leading to more income, fewer unhealthy habits, or reduced healthcare costs. Read here and here to consider whether you can afford not to go.

Disclaimer: this Good Faith Estimate shows the costs of services that are reasonably expected for your healthcare needs, based on information known at the time the estimate was created; actual charges may differ. Your therapist may use other service or diagnostic codes if necessary. This Good Faith Estimate is not a contract; it does not obligate you to obtain the aforementioned services from this therapist, or from any providers.

The Good Faith Estimate does not include any unknown or unexpected costs that may arise during treatment. You could be charged more if complications or special circumstances occur. If your bill exceeds this Good Faith Estimate by more than $400, you have the right to dispute the bill. Initiating a dispute will not adversely affect the quality of care that your therapist provides. You may contact your therapist to let them know the billed charges are higher than the Good Faith Estimate. You may ask them to update the bill to match the Good Faith Estimate, or you may negotiate the bill. You may also start a dispute resolution process through the U.S. Department of Health and Human Services. If you choose to use the dispute resolution process, you must start within 120 calendar days (about 4 months) of the date on the original bill. There is a $25 Federal fee to use the dispute process. A dispute resolution agency approved by HHS will review your dispute. If the agency agrees with you, you will not pay more than the price on this Good Faith Estimate. If the agency disagrees with you and agrees with the healthcare provider, you will have to pay the billed amount. To learn more and get a form to start the dispute process, visit the CMS website. For questions or more information about your right to a Good Faith Estimate, visit the CMS website.