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/nosurprise... 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 $180.00 for an intake and $150.00 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 $150.00 per visit, if you attend one psychotherapy visit per week, your estimated charge would be $600.00 for four visits provided over the course of one month; $1200.00 for eight visits over two months; or $1800.00 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 (following the initial assessment session at $180.00).

 

Number of Weeks	Total estimated charges for 1 session per week	Total estimated charges for 2 sessions per week
1 Week of Service	$150	$300
13 Weeks of Service (Approx. 3 Months)	$1,950	$3,900
26 Weeks of Service (Approx. 6 months)	$3,900	$7,800
39 Weeks of Service (Approx. 9 Months)	$5,850	$11,700
52 Weeks of Service (Approx. 12 Months)	$7,800	$15,600

 

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. Your signature acknowledges that you have been informed of this good faith estimate and are understanding of its contents and implications.  A copy of this GFE will be provided for you following your signature.

Client Signature: _____________________________________________________

Date of this Estimate_______/_______/_______