You are entitled to a good faith estimate of health care costs

No Surprises.

Who is Entitled to This?

Under the law, health care providers need to give patients who don’t have

insurance or who are not using insurance an estimate of the bill for medical

items and services.

Why is this important

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, visit

www.cms.gov/nosurprises

What is this? 

You have the right to receive a Good Faith Estimate for the total

expected cost of any non-emergency items or services. This includes

related costs like medical tests, prescription drugs, equipment, and

hospital fees.

When should you get this?

Make sure your health care provider gives you a Good Faith Estimate

in writing at least 1 business day before your medical service or item.

You can also ask your health care provider, and any other provider you

choose, for a Good Faith Estimate before you schedule an item or

service.

.

Sample GOOD FAITh ESTIMATE

Date of Good Faith Estimate:_____/________/___ 
The following is a detailed list of expected charges for an assessment session followed by individual and/or family psycho-therapy. “The estimated costs are valid for 12 months from the date of the Good Faith Estimate.”

 

Estimate
Mara Goldberg, LICSW

Next Chapter Counseling LLC

Street Address: 900 Cumming Center, Suite 416U
City: Beverly,  State: MA,  ZIP Code 01915
Contact Person- Mara Goldberg, LICSW

Phone 281-701-0092 Email mara@nextchaptercounselingllc.com
National Provider Identifier: 1073919734

Taxpayer Identification Number(EIN)82-3095279 
 

Diagnosis Code: TBD

Service Code 90791 60min Intake session with diagnosis

Cost per session: 145$

Service Code:90834 38-52 min psycho therapy

Cost per session: 120$

Service Code 90846-50 min family therapy without client present 

Cost per session: 120$

Service Code 90847- 50 min family therapy with client present

Cost per session: 120$

Service Code 90837 60 min psycho therapy

Cost per session 180$

 

Quantity Expected Cost: sessions are typically weekly. The number and frequency of sessions will be determined based on your progress towards your goals. A client who is seen for 50 weeks with an intake session can expect charges of between $6,025 and $8,965 for a year of sessions.

 

Total Expected Charges from Next Chapter Counseling $8965