Good Faith Estimate for Cost of Services
Please Note:
- The total for treatment services will be the number of sessions multiplied by the ongoing session fee.
- The number of total sessions in the treatment is unknown at the outset and is based on the patient’s needs, preferences, and the progress made in treatment.
- Although insurance companies may authorize services, they often do not guarantee payment and you will be ultimately responsible for the cost of services provided as outlined in the Good Faith Estimate, regardless of the reason they are not covered. It is important that you confirm exactly what mental health services your insurance policy covers. Please note that I do not accept insurance payments.
- If you are not using insurance, and/or will not receive insurance reimbursement the Good Faith Estimate is an estimate of the most you will be obliged to pay.
- This is not a contract and you are not required to receive these services.
Good Faith Estimate of Table of Services and Fees
The amount you will be obliged to pay may be less if you have insurance or other 3rd party payers
Service Description | Fee per Session/Service | ||
| 1 Session per week | 4 sessions or 1 month | 20 sessions or 6 months, assuming time off for cancellations |
Initial Intake Session, individual therapy (60 mins) | $175 | n/a | n/a |
Initial Intake Session: Family or Couples therapy (90 mins) | $250 | n/a | n/a |
Individual therapy (38-60 mins) | $175 | $700 | $3500 |
Family or Couples Therapy (68-90 minutes) | $250 | $1000 | $5000 |
Telephone assessment and Management | $25 + (Prorated hourly rate in 10-minute increments for time greater than 10 minutes) | ||
Online Digital evaluation and management | $25 + (Prorated hourly rate in 10-minute increments for time greater than 10 minutes) | ||
Cancellation fee—charged for short notice cancellations (< 24 hours) and no shows | Same as fee for individual or family/couples therapy as mentioned above. | ||
Other Therapist time: Reports, correspondence, staffing | $25 + (Prorated hourly rate in 10-minute increments for time greater than 10 minutes) | ||
Charges related to litigation, including preparation, court time, travel, etc | See disclosure statement | ||
| There are certain services that the Practice provides that may include, but are not limited to, telephone conversations/sessions, site visits, report writing and reading, drafting of summaries, consultations with other professionals, expenses related to any legal process (including attorney’s fees) in our efforts to comply with state and federal confidentiality requirements as well as the therapist’s time (portal to portal) or if a therapist is obligated to attend depositions or trial. If any of these uncovered services or expenses are provided or incurred, you will be charged at the private pay/non-insured patients hourly rate unless other arrangements have been made and agreed to and you agree that you will be obligated and will pay any such charges. You will be provided with an updated estimate should these circumstances arise. | ||
Total Cost | This Good Faith Estimate explains your therapist’s rate for each service provided. Your therapist’s 2023 rate is $175/session for individual therapy and $250 per session for family or couples therapy; however, your fee is adjusted to ___ per prior agreement. Your therapist will collaborate with you throughout your treatment to determine how many sessions and/or services you may need. It is your prerogative to stop therapy at any time. | ||
Individual Therapy
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Couple Therapy
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THE NO SURPRISES ACT: STANDARD NOTICE AND
CONSENT DOCUMENTS
(OMB Control Number: 0938-1401)
A new federal rule went into effect January 1, 2022 to protect consumers from surprise health care bills. This No Surprises Act requires medical workers, clinical social workers and other health care workers to provide a good faith estimate (GFE) of expected charges that may be billed for items and services to individuals who are:
- uninsured (e.g., not enrolled in any health plan or coverage)
- self-pay (e.g., not seeking to file a claim with their plan or coverage).
The rule applies to current and future clients. However, GFEs do not need to be provided to patients who are enrolled in federal health insurance plans (e.g. Medicare, Medicaid, TRICARE, Indian Health Service or the Veterans Affairs health system). GFEs also do not yet apply to other insurance plans when a client is working with in-network providers and using in-network insurance to pay for medical services.
SURPRISE BILLING PROTECTION
The purpose of this document is to let you know about your protections from unexpected medical bills. You’re getting this notice because this provider is not in your health plan’s network. Or the services you are receiving from this provider are not re-imbursed by your health insurance coverage. This means:
- You may pay more
- You may owe the full costs billed for the services you receive
- Your health plan might not count any of the amount you pay towards your deductible and out- of-pocket limit.
You may choose to get care from a provider in your health plan’s network. Before deciding whether to sign this form, you can contact your health plan to find an in-network provider or facility.
GOOD FAITH ESTIMATE (GFE)
You have the right to receive a Good Faith Estimate (GFE) for the total expected cost of any non-emergency healthcare services, in this case, art therapy and family therapy services. The GFE must be provided both orally and in writing, upon request or at the time of scheduling healthcare services, and within specific timeframes. Your healthcare provider must give you a GFE in writing at least one business day before your first appointment for medical (art therapy and family therapy) services. You may ask your healthcare provider for a GFE before you schedule therapy services. If you receive a bill that is at least $400 more than your annual Good Faith Estimate, you can dispute the bill.
Total cost estimate of what you may be asked to pay: It is your ethical right to determine your goals for treatment and how long you would like to remain in therapy, unless you are pursuing mandatory treatment. It is within your federal rights and protections to:
- Review your detailed estimate. Review the cost estimate for each psychotherapy service.
- Call your health plan. Your plan may have better information about how much of these services are reimbursable.
- Ask questions about this notice and estimate: Talk with your therapist.
- Ask questions about your rights under this federal act: Contact: The U.S. Centers for Medicare & Medicaid Services (CMS) at 1- 800-MEDICARE (1-800-633-4227) or Illinois Department of Insurance, Office of Consumer Health Insurance at (877) 527-9431.
- Ask about prior authorization or other care management limitations: Except in an emergency, your health plan may require prior authorization (or other limitations) for certain services. This means you may need your plan’s approval before you receive certain services. If prior authorization is required, ask your health plan about what information is necessary to get coverage.
- Read more information about your rights and protections under federal law visit: https://www.cms.gov/files/document/model-disclosure-notice-patient-protections-against-surprise-billing-providers-facilities-health.pdf
Keep a copy of this form. It contains important information about your rights and protections.
Heart to Heart Therapist
NPI#: 1841624442
Individual Therapy
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