Good Faith Estimate (GFE) Disclosure
As of January 1, 2022, healthcare providers must provide all clients with a Good Faith Estimate (GFE). The disclosure of the Good Faith Estimate provides essential facts and is not the actual estimate.
· You are entitled to receive this Good Faith Estimate of what the charges could be for psychotherapy services provided to you. While it is not possible for a psychotherapist to know, in advance, how many psychotherapy sessions may be necessary or appropriate for a given person, this form provides an estimate of the cost of services provided.
· The total cost of services will depend upon the number of psychotherapy sessions you attend, your circumstances, and the type and amount of services that are provided for you. A Good Faith Estimate will be provided through your SimplePractice Client Portal.
· The Good Faith Estimate (GFE) shows the costs of items and services that are reasonably expected for my mental health services and psychotherapy needs for an item or service.
· The estimate is based on an assessment, and actual charges may differ when the estimate is created. The estimated costs are valid for twelve months from the date of the Good Faith Estimate.
· Additional items or services may be recommended as part of your psychotherapy care that must be scheduled or requested separately and are not reflected in this reasonable faith estimate.
· This estimate is not a contract and does not obligate you to obtain any services from the provider(s) listed, nor does it include any services rendered to you that are not identified here.
· You have the right to initiate a dispute resolution process if the actual amount charged to you substantially exceeds the estimated charges stated in your Good Faith Estimate (which means $400 or more beyond the estimated charges).
· The standard session fees are (in person or via telehealth) are $180 for a 50-minute individual session and $270 for a 90-minute couple therapy session. Most clients will attend one psychotherapy visit per week, but the frequency of psychotherapy visits that are appropriate in your case may be more or less than once per week, depending upon your needs.
· If additional time is requested for extended sessions, you will be billed $180 50-minute individual therapy session and $270 for a 90-minute couple therapy session.
· The Good Faith Estimate you receive will estimate the cost of weekly therapy throughout 12, 24, 36, & 52 weeks providing you with an estimate of expected charges of psychotherapy services.
· If you change session frequency or change fee structures, you will be provided a new Good Faith Estimate reflecting these changes.
· The Good Faith Estimate is not intended to serve as a recommendation for treatment or a prediction that you may need to attend a specified number of psychotherapy visits.
· The number of appropriate psychotherapy visits and the estimated cost for those services in your case will depend upon your needs and what you agree to in consultation with your therapist.
· You are entitled to disagree with any recommendations concerning your treatment. You are free to discontinue and end psychotherapy services at any time. You are not under obligation for any number of psychotherapy sessions.
· You are encouraged to speak with your provider at any time about any questions you may have regarding your treatment plan or the information provided to you in the Good Faith Estimate (GFE).
· Disclaimer: The Good Faith Estimate shows the costs of items and services that are reasonably expected for your mental health care needs for an item or service. The estimate is based on information known at the time the estimate was created.
· Disclaimer: The Good Faith Estimate (GFE) does not include any unknown or unexpected costs that may arise during treatment. There may be additional services requested separately. There is the potential to be charged more if complications or exceptional circumstances arise. Federal law allows me to dispute (appeal) the bill if this happens.
· If the bill is higher than this Good Faith Estimate (GFE), I have the right to dispute the bill. I may contact the provider listed to let them know the bill charges are higher than the Good Faith Estimate (GFE). 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
· I may start a dispute resolution process with the U.S. Department of Health and Human Services (HHS). If I choose to use the dispute resolution process, I must start the dispute process within 120 calendar days (four 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 (GFE). If the agency disagrees with you and agrees with the health care provider or facility, you will have to pay the higher amount.
· The Good Faith Estimate (GFE) is not a contract and does not require the uninsured or self-pay individual to obtain the items or services from any provider identified in the Good Faith Estimate (GFE).
· There is a 24-hour cancellation policy. If you cannot attend a session and do not provide 24 hours’ notice, you will be responsible for paying for that missed psychotherapy session.
· For questions or more information about your right to a Good Faith Estimate or the dispute process, visit https://www.cms.gov/nosurprises/consumers or call Health & Human Services 1-800-985-3059. The patient-provider dispute resolution process initiation will not adversely affect the quality of services furnished to you.
Adapted From California Association of Marriage and Family Therapists I Rev, 2022