No Surprises Act/ Good Faith Estimate

GOOD FAITH ESTIMATE (GFE)

In compliance with the No Surprises Act that went into effect on January 1, 2022, all healthcare providers are required to notify clients of their Federal rights and protections against “surprise billing.”

This Act requires that we notify you of your federally protected rights to receive a notification when services are rendered by an out-of-network provider, if a client is uninsured, or if a client elects not to use their insurance.

Additionally, we are required to provide you with a Good Faith Estimate of the cost of services (attached). It is difficult to determine the true length of treatment for mental health care, and each client has a right to decide how long they would like to participate in mental health care. Therefore, attached, you will find a fee schedule for the services typically offered by your therapist, and we will collaborate with you on a regular basis to determine how many sessions you may need.

It is a Federal requirement that we have each client sign this form to begin/resume treatment. Please sign and date before your next appointment. If you have any questions, please don’t hesitate to ask.

Thank you very much,
Jennifer Finch, LPC, NCC, SEP

Provider Name: Jennifer Finch

License/#: LPC004375

Provider Address: TeleMental Health

Provider Phone #: (678) 428-2730

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 60-minute psychotherapy visit (in-person or via telehealth) is $250.00.  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. 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 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.         

This GFE is not a contract.  It does not obligate you to accept the services listed above.

 Keep a copy of this Good Faith Estimate (GFE) in a safe place or take pictures of it.

PLEASE SIGN AND COMPLETE THE ELECTRONIC FORM BELOW TO ACKNOWLEDGE THAT YOU HAVE READ AND UNDERSTAND THE INFORMATION DESCRIBED HEREIN AND THAT YOU HAVE DISCUSSED WITH ME ANY PART OF THE INFORMATION YOU DO NOT UNDERSTAND.

THE ORIGINAL COPY OF THIS DOCUMENT WILL REMAIN IN MY FILE; FOR A PERSONAL COPY, YOU ARE RESPONSIBLE FOR PRINTING ON YOUR OWN.

“I UNDERSTAND THE FINANCIAL POLICY, AND THE GOOD FAITH ESTIMATE. I ALSO UNDERSTAND THAT THIS PROVIDER IS NOT ON INSURANCE PANELS AND DOES NOT FILE INSURANCE CLAIMS.”