Patient Resources

The estimate below is the range of costs for new patients.  Until we complete an initial evaluation, and begin care, we will not have a clear picture of your specific diagnosis, issues, and needs. We typically see therapy patients for 25 sessions for a total cost of $3850.00.  But in some/many cases a patient’s issues may be more complicated, so we may need additional sessions during the time covered by this estimate. We typically see medication management patients for a total cost of $1900. But in some/many cases a patient’s issues may be more complicated, so we may need additional sessions during the time covered by this estimate.

Continuing Patient Explanation

The estimate below is the range of costs/cost that we think is likely for your care over the time covered by this estimate.  However, depending on how treatment progresses, more or fewer sessions or appointments may be needed.  Contact: If you have questions about this estimate, please contact our billing department at 305-279-2276.

Details of the Estimate

The following is a detailed list of expected charges for psychological services scheduled:

                   to                 .  The estimated costs are valid for 12 months from the date of this Good Faith Estimate.

Disclaimer

This Good Faith Estimate shows the costs of services that are reasonably expected for the expected services to address your mental health care needs. The estimate is based on the information known to [us/me] when [we/I] did the estimate. 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 this happens, federal law allows you to dispute (appeal) the bill.

You may contact the billing department at the contact listed above to let them know the billed charges are at least $400 higher than the Good Faith Estimate. You can ask them to update the bill to match the Good Faith Estimate, ask to negotiate the bill, or ask if there is financial assistance available. 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 original 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 this Good Faith Estimate. If the agency disagrees with you and agrees with the health care provider or facility, 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 CMS at 1-800-985-3059. For questions or more information about your right to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprises or call CMS at 1-800-985-3059.

• This Good Faith Estimate is not a contract. It does not obligate you to accept the services listed above.

• Keep a copy of this Good Faith Estimate (GFE) in a safe place. If at any time during your treatment the above expected charges do not match with your payments, you have the right to dispute it at any time.