GOOD FAITH ESTIMATE

You are entitled to receive this “Good Faith Estimate” of what the charges could be for psychotherapy services provided to you. The aim of the Good Faith Estimate law is to prevent healthcare patients and clients from getting surprise bills from out-of-network providers. The estimate is based on information known at the time the estimate was created. This estimate does not include any unknown or unexpected costs that may arise once the service begins. You will be notified if additional costs will be required. If you are billed more than the Good Faith Estimate, you have the right to dispute the bill. To do this, please contact the health care provider listed above (dreehwa@gmail.com or 415-799-1174). If this is not resolved satisfactorily, you can start a dispute resolution with the U.S. Department of Health & Human Services (HHS). You must start this process within 120 calendar days of the date of the original bill. There is a $25 fee to use the HHS dispute process. If the agency agrees with you, you will pay the amount on this estimate. If the agency disagrees with you, you will pay the higher billed amount to the health care provider. To learn more or start the process, go to: www.cms.gov/nosurprises.

While it is not possible for a psychologist 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 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.

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 you agree to in consultation with your therapist. You are entitled to disagree with any recommendations made to you concerning your treatment and you may discontinue treatment at any time.

The estimated cost is based on the requested service and the information initially provided by the patient/parent. If the service plan changes based on patient/parent request or additional information, a new estimate will be provided, and the patient/parent can decide whether or not they want the service. You have a 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).

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 this Good Faith Estimate. Please keep a copy of your Good Faith Estimate.