Under Section 2799B-6 of the Public Health Service Act, you have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost.
- You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services.
- Make sure your healthcare provider gives you a Good Faith Estimate in writing at least 1 business day before your medical service. You can also ask your healthcare 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.
- 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 price on the Good Faith Estimate. If the agency disagrees with you, your provider will pay the higher amount.
- Make sure to save a copy or picture of your Good Faith Estimate.
For questions or more information regarding your Good Faith Estimate, visit http://www.cms.gov/nosurprises or call 1-800-985-305.
Service Information
Common Services
90837: 50-minute therapy session $100
Cancellation Fee: $100 (24-hour cancellation notice is required or a full session fee may be a charge)
Other: For additional services such as phone calls over 10 minutes or longer sessions, a prorated amount based on an hourly fee of $100 will apply.
Where Services will be Received
Online, via telehealth
Estimate for Cost of Services
Due to therapy’s highly personal nature, it is difficult (if not impossible) to predict how long and how often we will meet. We will make these decisions collaboratively and discuss them throughout our work together. Per the Disclosure and Consent form, you can discontinue services at any time.