Notice of Good Faith Estimate

Notice of Good Faith Estimate                                                                        
You have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost. 
Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services. 

1. You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. 
2. Make sure your health care provider gives you a Good Faith Estimate in writing at least 1 business day before your medical service or item. 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.
3. If you receive a bill that is at least $400 or more than your Good Faith Estimate, you can dispute the bill.
4. Make sure you save a copy or picture of your Good Faith Estimate.

For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprise or call1-800-985-3059

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Good Faith Estimate for Health Care Costs and Services

Good Faith Estimate for Healthcare Costs and Services
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Patient Name:                    Date of Birth:
Date of Estimate:

Depending on our progress, I expect that my care of you will require continued weekly therapy sessions continuing the end of the year as follows:
The Estimated costs are valid for 12 months from the date of the Good Faith Estimate. 

Service Code:     90837 Individual Psychotherapy, 55 minutes
Diagnosis Code: xxxx
Cost:                    $150
Quantity:              52 
Total Cost:           $ 7,800.00
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Disclaimer
This Good Faith Estimate shows the costs of items and services that are reasonably expected for your health care needs for an item or service. The estimate is based on information known at the time the estate was created. The Good Faith Estimate does not include any unknown or unexpected costs that may arise during treatment. Your signature does not require you to receive psychotherapy services from me. 

Good Faith Estimate for Health Care Costs and Services for Intake

Good Faith Estimate for Healthcare Costs and Services
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Patient Name:                    Date of Birth:
Date of Estimate:

Depending on our progress, I expect that my care of you will require continued weekly therapy sessions continuing the end of the year as follows:
The Estimated costs are valid for 12 months from the date of the Good Faith Estimate. 

Service Code:     90791 Diagnostic Interview
Diagnosis Code: Z03.89
Cost:                    $150.00
Quantity:              1 
Total Cost:           $ 150.00
​
Disclaimer
This Good Faith Estimate shows the costs of items and services that are reasonably expected for your health care needs for an item or service. The estimate is based on information known at the time the estate was created. The Good Faith Estimate does not include any unknown or unexpected costs that may arise during treatment. Your signature does not require you to receive psychotherapy services from me.