Good Faith Estimate

Notice to clients and prospective clients:

Under the law, health care providers need to give clients who don’t have insurance or who are not using insurance an estimate of the expected charges for medical services, including psychotherapy services.

 

You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency healthcare services, including psychotherapy services.

You can ask your health care provider, and any other provider you choose, for a

 

Good Faith Estimate before you schedule a service, or at any time during treatment.

 

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, or how to dispute a bill, see your Estimate, or visit www.cms.gov/nosurprises.

 

Good Faith Estimate

Services Requested (Type and Codes): 90791 - Professional Evaluation, 90832 - Psychotherapy 30 minutes, 90834 - Psychotherapy 60 minutes, 90847- Family Psychotherapy with Patient Present 60 minutes, 90846 - Family Psychotherapy without Patient Present 60 minutes, 90791-95 Professional Evaluation via Telehealth, 90832-95 - Psychotherapy 30 minutes via Telehealth, 90834-95 - Psychotherapy 60 minutes via Telehealth, 90847-95 Family Psychotherapy with Patient Present 60 minutes via Telehealth, 90846-95 Family Psychotherapy without Patient Present 60 minutes via Telehealth, No Show/Late Cancellation Fee (Less than 24 hr notice)

 

Provider: The Held Self Therapy PLLC

Provider Address: 1600 W Chandler Blvd, Ste 100, Chandler, AZ 85224

Provider Phone #: (480) 269-3029

Provider Tax ID# (if applicable): 42-2400115

Provider NPI # (if applicable): 1891599742

 

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. 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 that may be recommended during treatment to you that are not identified here.

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.

 

The fee for a 60-minute psychotherapy visit (in person or via telehealth) is $175.00. In the event that a session exceeds 60 minutes an additional $87.20 will be charged for each additional 30 minutes over the 60 minute session. The fee for a no show or cancellation less than 24 hours is $175. 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 on this per visit fee cited above, the following are expected charges of weekly psychotherapy services.

 

1 month (4 sessions) $700.00

6 months (24 sessions) $4,200.00

12 months (48 sessions) $8,400.00