Clients who are paying out-of-pocket and who are not submitting claims to their insurance company for out of network services provided by Valerie Epstein-Johnson are entitled to a “Good Faith Estimate” of your costs for psychotherapy services. This estimate will be specific to you and the services you have agreed to receive at the frequency you have agreed to receive them over the course of one year. If you or your provider specify a briefer length of treatment at the outset of treatment, the estimate will feature an estimated cost for this length of treatment at the agreed upon frequency of sessions.
While it is not possible for a psychotherapist to know, in advance, the exact number of sessions necessary or appropriate for a given person, this form will provide/document the estimate of the cost of services to be provided. Your total cost of services will depend on the number of psychotherapy sessions you attend, your individual circumstances and the type of services that are provided to you.
The Good Faith Estimate is not a contract and does not obligate you to obtain any services from Valerie Epstein-Johnson, LPC, ATR-BC, LLC nor does it include any services that may be recommended during treatment to you that are not identified here.
The “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 provider. You are entitled to disagree with any recommendations made to you concerning your treatment and you may discontinue treatment at any time.
55 min. session rate as of 10/2021: $150
Total Estimated Charges for attending 1 session per week for 12 months: $7800.
This estimate does not take into account expected cancellations and breaks in treatment due to client or therapist illness, vacations, and other life events that might warrant a change to the number of sessions you will have over the course of the year. Meeting less frequently than weekly will, of course, result in a lower yearly expense; meeting more frequently than once a week by agreement between you and your provider temporarily or ongoing, will result in a higher yearly expense than this estimate states. If you make this kind of change in frequency in agreement with your provider during the course of treatment, you are entitled to receive a new estimate reflecting that change.
Legal Disclaimers of the No Surprises Act
This Good Faith Estimate shows the costs of services that are reasonably expected for services to address your mental health care needs. The estimate is based on the information known to me when I did the estimate.
The Good Faith Estimate does not include any unknown or unexpected costs that may arise during treatment. It does not include cost estimates for services outside of recurring psychotherapy sessions such as charges to complete paperwork, write letters or write summaries of treatment; it does not include costs related to complying with court ordered preparation of services or attendance related to legal issues. These costs are outlined in the “Practice Policies” document signed at the start of therapy.
You have a right to dispute a bill 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 for recurring psychotherapy sessions).
You may contact the psychotherapist at the contact information listed above to let them know the billed charges are substantially higher than the Good Faith Estimate. You can ask them to update the bill to match the Good Faith Estimate, ask to negotiate the bill, or ask if there is financial assistance available.
You may also start a dispute resolution process with the U.S. Department of Health and Human Services (HHS). If you choose to use the dispute resolution process, you must start the dispute process within 120 calendar days (about 4 months) of the date on the original bill. There is a $25 fee to use the dispute process. If the agency reviewing your dispute agrees with you, you will have to pay the price on this Good Faith Estimate. If the agency disagrees with you and agrees with the health care provider or facility, you will have to pay the higher amount.
For questions or more information about your right to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprises/consumers or call CMS at 1-800-985-3059.
You are encouraged to speak with your provider at any time about any questions you may have about the information provided to you in this Good Faith Estimate.
