Good Faith Estimate

Under Section 2799B-6 of the Public Health Service Act, health care providers and health care facilities

are required to inform (both orally and in writing) individuals who are not enrolled in an insurance plan or coverage, or a Federal health care program, or are not seeking to file a claim with their insurance plan or coverage of their ability, to receive a “Good Faith Estimate” of expected charges. This good faith estimate can be received upon request or at the time of scheduling health care items and services.

This form may be used by the health care providers to inform individuals who are not enrolled in an insurance plan or coverage, or a Federal health care program (uninsured individuals), or individuals who are enrolled but not seeking to file a claim with their plan or coverage (self-pay individuals) of their right to a “Good Faith Estimate” to help them estimate the expected charges they may be billed for receiving certain health care items and services. Below is an example of a "good faith estimate".

GOOD FAITH ESTIMATE

Provider	UT License #
Provider Address: 5149 South 1500 West Riverdale, Utah 84405
Provider Phone #: (801) 475-0402
Provider Tax ID#	Provider NPI #

Patient Name:	Patient Date of Birth:
Patient Address (include if telehealth):
Patient Diagnosis (if known/applicable):
Services Requested:	Date of Initial Session (if applicable):

You are entitled to receive this “Good Faith Estimate” of what the charges could be for psychotherapy services provided to you. While it is not possible for a psychotherapist to know, in advance, how many psychotherapy sessions may be necessary or appropriate for a given person, this form provides an estimate of the cost of services 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 estimate is not a contract and does not obligate you to obtain any services from the provider(s) listed, nor does it include any services rendered to you that are not identified here.

You have the right to initiate a dispute resolution process 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 questions or more information about your right to a Good Faith Estimate or the dispute process, visit https://www.cms.gov/nosurprises/consumers or call 1- 800-985-3059. The initiation of the patient-provider dispute resolution process will not adversely affect the quality of the services furnished to you.

The fee for a 50-minute psychotherapy visit (in-person or via telehealth) is $150.00 for an intake and $125.00 for each subsequent session. Most clients will attend one psychotherapy visit per week, but the frequency of psychotherapy visits that are appropriate in your case may be more or less than once per week, depending upon your needs. Based upon a fee of $125.00 per visit after completing your $150 intake), if you attend one psychotherapy visit per week, your estimated charge would be $525.00 for four visits provided over the course of one month; $1025.00 for eight visits over two months; or $1525.00 for 12 visits over three months and so on. If you attend therapy for a longer period, your total estimated charges will increase according to the number of visits and length of treatment. This is further explained in the following chart (after having completed the $150 intake session).

Number of Weeks	Total estimated charges for 1 session per week	Total estimated charges for 2 sessions per week
1 Week of Service	$125	$250
13 Weeks of Service (Approx. 3 Months)	$1625	$3250
26 Weeks of Service (Approx. 6 months)	$3250	$6500
39 Weeks of Service (Approx. 9 months)	$4875	$9750
52 Weeks of Service (Approx. 12 Months)	$6500	$13000

This 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 therapist. You are entitled to disagree with any recommendations made to you concerning your treatment and you may discontinue treatment at any time.

You are encouraged to speak with your provider at any time about any questions you may have regarding your treatment plan, or the information provided to you in this Good Faith Estimate.

Date of this Estimate _________________________________________________

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