Under Section 2799B-6 of the Public Health Service Act, I am required to provide a good faith estimate of expected charges for items and services to individuals who are not enrolled in an insurance plan or coverage or a Federal health care program, or not seeking to file a claim with their plan or coverage. As I am an out-of-network private practice provider, the latter criteria apply to you with regard to how you pay for the psychological services I provide. The information in the good faith estimate is only an estimate, which means that actual services or charges may differ from the good faith estimate. Among other reasons, this is because the total financial estimate for care prior to initial diagnostic sessions are difficult to calculate. Most clients experiencing psychological and emotional distress requiring psychotherapy services accompanying ICD-10/DSM diagnosis should plan for weekly therapy visits at my established and/or agreed upon rate. Therefore, the Good Faith Estimate provides just that—an estimate of the cost of services to be 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.

There may be additional items or services I may recommend as part of your care that must be scheduled or requested separately and are not reflected in this good faith estimate. This good faith estimate is not a contract and does not require nor obligate you to obtain any services from me, nor does it include any services rendered to you that are not identified here.

If you see unexpected charges or disagree with any charges, please reach out to me so that we can have a conversation about the charges. You also have the right to initiate a dispute resolution process with the U.S. Department of Health and Human Services (HHS). Actual amount charged to you must substantially exceed the estimated charges stated in your Good Faith Estimate (which, according to Section 2799B-6 of the Public Health Services Act, means $400 or more beyond the estimated charges). If you choose to use the dispute resolution process, you must start the dispute process within 120 calendar days of the date on the original bill. To learn more and get a form to start the process, visit www.cms.gov/nosurprises/consumers or call 1-800-985-3059.

Please note that the initiation of the patient-provider dispute resolution process will not adversely affect the quality of the services furnished to you.