Sample Good Faith Estimate Notice

 

Notice to clients and prospective clients:

Under the law, health care providers need to give clients who don’t have insurance or who are not using insurance an estimate of the expected charges for medical services, including psychotherapy services. 

You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency healthcare services, including psychotherapy services.

You can ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule a service, or at any time during treatment.  

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 picture of your Good Faith Estimate. 

 For questions or more information about your right to a Good Faith Estimate, or how to dispute a bill, see your Estimate, or visit www.cms.gov/nosurprises. 

  INSURANCE ACCEPTED

   REGENCE

   PROVIDENCE

   UNITED BEHAVIORAL HEALTH

   OHP (OPEN CARD ONLY)

   AETNA

   OUT OF NETWORK: CHECK WITH YOUR INSURANCE FOR MENTAL HEALTH COSTS ASSOCIATED WITH YOUR BENEFITS PLAN

OUT OF POCKET PAYERS

           INDIVIDUAL $90 THERAPY SESSION / $100 INTAKE SESSION

           COUPLE      $100  THERAPY SESSION / $110 INTAKE SESSION

           CHILDREN AGES 7-12   30 MIN $55      50 MIN $90

ALL THERAPY SESSIONS ARE 45-50 MIN        INTAKE SESSION IS 50-60MIN

SUPERVISION 

   REGISTERED ASSOCIATES  $90

   GRADUATE STUDENTS  $75