No Surprises Act

You have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost. Under the No Surprises Act, 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 services, including psychotherapy. You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency services. Make sure your health care provider gives you a Good Faith Estimate in writing at least 1 business day before your medical service. You can also ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule a service. If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill. Make sure to save a copy or take a picture of your Good Faith Estimate.

For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises or send a text message to (415) 439-0518.

 

Good Faith Estimate

GOOD FAITH ESTIMATE FOR CHASE THERAPY SERVICES

(In compliance with Federal No Surprises Act)

The following is your Good Faith Estimate for psychotherapy sessions with your therapist:

  • Type of service: Individual Psychotherapy
  • Service code: 90834 (individual therapy)
  • Applicable diagnosis codes: Typical example could be F43.2, Adjustment Disorder
  • Date(s) of service: Recurring weekly (or as agreed)
  • Estimated number of sessions: 24-50 sessions in a year
  • Individual therapy
    • Cost of sessions: $160-$225 per session
    • Estimated total cost: $3,840 - $11,250*

*Note: Estimated costs are valid for 12 months from the date of this Good Faith Estimate which will be the same date as your signed consent form.

Keep in mind, therapy is an investment in yourself: For many people, it can save money through greater productivity leading to more income, fewer unhealthy habits, or reduced healthcare costs. Read Mental health can greatly impact our financial lives and consider whether you can afford not to invest in yourself 10 Reasons therapy helps you make more money.

 

Disclaimer

Disclaimer: This Good Faith Estimate shows the costs of services that are reasonably expected for your health care needs, based on information known at the time the estimate was created; actual charges may differ. Your therapist may use other service or diagnostic codes if necessary. This Good Faith Estimate is not a contract; it does not obligate you to obtain the aforementioned services from this therapist, or from any reflect providers.

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 your bill exceeds this Good Faith Estimate by more than $400, you have the right to dispute the bill Initiating a dispute will not adversely affect the quality of care that your therapist provides. You may contact your therapist to let them know the billed charges are higher than the Good Faith Estimate. You may ask them to update the bill to match the Good Faith Estimate, or you may negotiate the bill. You may also start a dispute resolution process through the U.S. Department of Health and Human Services. If you choose to use the dispute resolution process, you must start within 120 calendar days (about 4 months) of the date on the original bill. There is a $25 Federal fee to use the dispute process. A dispute resolution agency approved by HHS will review your dispute. If the agency agrees with you, you will not pay more than the price on this Good Faith Estimate. If the agency disagrees with you and agrees with the health care provider, you will have to pay the billed amount. To learn more and get a form to start the dispute process click here. For questions or more information about your right to a Good Faith Estimate click here.