Good Faith Estimate for Services
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. Your total cost of services will depend upon the number of psychotherapy sessions you attend, your individual needs and circumstances, and the type and amount of services that are provided to you.
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.
Disclaimer
This 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 visits that are appropriate in your case, and the estimated cost for those services, depends on your needs and what we agree to in consultation. You are entitled to disagree with any recommendations made to you concerning your treatment and you may discontinue treatment at any time.
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 estimate was created.
This 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.
At most, your treatment will include a diagnostic evaluation (90791), billed at $120 for 60-minute visit, followed by recurring psychotherapy services. The fee for a 45-minute psychotherapy visit is $80. The fee for a 60-minute psychotherapy visit is $100. Most clients will attend one psychotherapy visit per week or one psychotherapy visit per 2 weeks, 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 you have negotiated a reduced rate with the therapist, your fees for services will be less than estimated below based on the negotiated reduced rate. These are the maximum fees charged.
Based on a fee of $80 (90834) or $100 (90837) per visit, the following are the at most expected charges of psychotherapy services:
Total estimated charges for 1 session per 2 weeks:
Service Period
45-minute sessions (90834)
60-minute sessions (90837)
4 Weeks of Service (Approx. 1 Month)
$80 x 2 sessions = $160
$100 x 2 sessions = $200
12 Weeks of Service (Appox. 3 Months)
$80 x 6 sessions = $480
$100 x 6 sessions = $600
26 Weeks of Service (Approx. 6 months)
$80 x 13 sessions = $1040
$100 x 13 sessions = $1300
38 Weeks of Service (Approx. 9 months)
$80 x 19 sessions = $1520
$100 x 19 sessions = $1900
52 Weeks of Service (Approx. 12 Months)
$80 x 26 sessions = $2080
$100 x 26 sessions = $2600
Total estimated charges for 1 session per week:
Service Period
45-minute sessions (90834)
60-minute sessions (90837)
4 Weeks of Service (Approx. 1 Month)
$80 x 4 sessions = $320
$100 x 4 sessions = $400
12 Weeks of Service (Appox. 3 Months)
$80 x 12 sessions = $960
$100 x 12 sessions = $1200
26 Weeks of Service (Approx. 6 months)
$80 x 26 sessions = $2080
$100 x 26 sessions = $2600
38 Weeks of Service (Approx. 9 months)
$80 x 38 sessions = $3040
$100 x 38 sessions = $3800
52 Weeks of Service (Approx. 12 Months)
$80 x 52 sessions = $4160
$100 x 52 sessions = $5200
There may be additional items or services recommended as part of the course of treatment that would be scheduled or requested separately and are not reflected in this good faith estimate. These additional services may include:
· Diagnostic Evaluation (90791), billed at $120 per 60-minute session
· Psychotherapy (90834), billed at $80 per 45-minute session
· Psychotherapy (90837), billed at $100 per 60-minute session
· Psychotherapy for Crisis (90839) billed at $15 per 15-minutes
· Fees incurred because of a missed session (cancellation or no show)
· Fees incurred for document requests, court documents, and other processing duties
Group Therapy billed at $25 per hour.
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Insurance
I am glad to submit claims directly to your insurance company as a courtesy to you; however, it is your responsibility to know your insurance coverage for mental health services as you are responsible for any portion of fees not covered by your insurance company. Please take special note of any co-pay, co-insurance, and deductible information as well as in-network and out-of-network rates. Please contact me to see if I am in network with your insurance provider.
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Late Cancellation/No-Show Policy
If you are unable to keep your appointment, please cancel by calling 812-797-0620 and leaving a message at least 24 hours in advance or logging into your client portal 24 hours in advance. This allows another client to schedule in your place. Clients who do not cancel 24 hours in advance may be charged a $40 missed appointment fee.