No Surprise Act Good Faith Estimate
NOTICE
Effective January 1, 2022
Under the “No Surprises Act”
You have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost.
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.
• 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.
• 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.
• 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 or call 1-800-985-3059
GOOD FAITH ESTIMATE FOR HEALTHCARE COSTS AND SERVICES
At Solutions Counseling and Consulting, we provide treatment based on individual needs. We are unable to predict a person’s rate/speed of progress. All Initial consultations/assessments are $150 and follow up, 60-minute sessions are $100. If you attend the initial assessment and 12 follow up sessions your cost of services would be $1350.00 {$150 + (12 x $100) = $1350.00}. Depending on your progress, your treatment may require weekly counseling sessions. The Good Faith Estimate is NOT a contract binding you to treatment services, it is simply an estimated cost of treatment if you choose to participate in weekly sessions for one year.
Estimated costs as follows:
| Service Code | Service/Item | Diagnosis Code | Cost Each | Quantity | Total Cost |
| 90791 | Initial Consultation | R69 | $150 | 1 | $150.00 |
| 90837 | Individual Psychotherapy, 60 minutes | R69 | $100 | 52 | $5200.00 |
| 90847 | Family/couples Psychotherapy, 60 minutes | R69 | $100 |
|
|
|
| Total Expected Charges |
|
|
| $5,350.00 |
All services will be provided by:
☐ Stacy Savage, M.S., LMHC, MCAP, National Provider Identifier: 1053575530, Taxpayer ID: 20-2325185
☐ Ashley Goetsch, M.S., LMHC, National Provider Identifier: 1982071882, Taxpayer ID: 20-2325185
☐ Rachel Scott, M.S., LMHC, National Provider Identifier: 1164879466, Taxpayer ID: 20-2325185
☐ Jessica Cavinta, M.S., LMHC, National Provider Identifier: 1093223844, Taxpayer ID: 20-2325185
Services will be provided at:
381 SW Palm Coast Pkwy, Suite 1 * Palm Coast, FL 32137 or Telehealth * Phone: (386) 597-2904 * Fax (386) 597-2903
Contact: Cindy Byrne Office Manager * Email: [email protected].
The estimated costs are valid for 12 months from the date of the Good Faith Estimate.
Disclaimer
This Good Faith Estimate shows the costs of items and services that are reasonably expected for your health care needs for an item or service. The estimate is based on information known at the time the estimate was created. The Good Faith Estimate does not include any unknown or unexpected costs that may arise during treatment. You could be charged more if complications or special circumstances occur. If this happens, federal law allows you to dispute (appeal) the bill.
If you are billed for more than this Good Faith Estimate, you have the right to dispute the bill. You may contact the health care provider or facility listed to let them know the billed charges are higher than the Good Faith Estimate. You can ask them to update the bill to match the Good Faith Estimate, ask to negotiate the bill, or ask if there is financial assistance available. If you receive a bill that is at least $400 more than your Good Faith Estimate, you may also start the dispute resolution process with the U.S. Department of Health and Human Services (HHS). If you choose to use the dispute resolution process, you must start the dispute process within 120 calendar days (about 4 months) of the date on the original bill. There is a $25 fee to use the dispute process. If the agency reviewing your dispute agrees with you, you will have to pay the price on this Good Faith Estimate. If the agency disagrees with you and agrees with the health care provider or facility, you will have to pay the higher amount. To learn more and get a form to start the process, visit www.cms.gov/nosurprises or call 1-800-985-3059. For questions or more information about your right to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprises or call 1-800-985-3059
Keep a copy of this Good Faith Estimate in a safe place or take pictures of it. You may need it if you are billed a higher amount.