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.
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.
.
Why is this important
If you receive a bill that is at least $400 more than your Good Faith
Estimate, you can dispute the bill.
• Make sure to save a copy or picture of your Good Faith Estimate.
For questions or more information about your right to a Good Faith Estimate, visit
What is this?
You have the right to receive a Good Faith Estimate for the total
expected cost of any non-emergency items or services. This includes
related costs like medical tests, prescription drugs, equipment, and
hospital fees.
Sample GOOD FAITh ESTIMATE
Date of Good Faith Estimate:_____/________/___
The following is a detailed list of expected charges for an assessment session followed by individual and/or family psycho-therapy. “The estimated costs are valid for 12 months from the date of the Good Faith Estimate.”
Estimate
Mara Goldberg, LICSW
Next Chapter Counseling LLC
Street Address: 900 Cumming Center, Suite 416U
City: Beverly, State: MA, ZIP Code 01915
Contact Person- Mara Goldberg, LICSW
Phone 281-701-0092 Email mara@nextchaptercounselingllc.com
National Provider Identifier: 1073919734
Taxpayer Identification Number(EIN)82-3095279
Diagnosis Code: TBD
Service Code 90791 60min Intake session with diagnosis
Cost per session: 145$
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