Good Faith
Estimate
Your right to understand the expected cost of care before your first appointment.
Integrity and transparency are two of the core values of Ariel McKinney PhD, PLLC. We go out of our way to make sure clients are treated with fairness, dignity, and respect. One way we intend to demonstrate this value is to ensure our clients are well informed of the cost and risks of treatment prior to their first appointment.
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 need 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. Also, please note that this Good Faith Estimate does not include non-medical costs of service that may incur over the course of psychotherapy.
At Ariel McKinney PhD, PLLC treatment usually begins with weekly sessions for preferably 6 consecutive weeks. You and your therapist will continually assess the appropriate frequency of therapy sessions and the plan for discharge. Duration of treatment typically lasts 3–6 months, however, the frequency and length of psychotherapy visits may be more or less depending on the following factors: individual needs/preferences, schedule and life circumstances, therapist availability, the nature of your specific life challenges and how you address them, and personal finances.
You and your therapist will continually assess the appropriate frequency of therapy sessions and the plan for or discharge and/or a new "Good Faith Estimate" will be issued should the frequency of session(s) or needs change. As related, you may request a new Good Faith Estimate at any time in writing during your treatment.
| Service | CPT Code | Rate | 6 Sessions | 12 Sessions 3–4 months |
24 Sessions 6–8 months |
32 Sessions 8–10 months |
|---|---|---|---|---|---|---|
|
Individual Psychotherapy
55–60 minutes
|
90837 | $235/hr | $1,410 | $2,820 | $5,640 | $7,520 |
|
Individual Psychotherapy
90 minutes
|
90834x2 | $352.50 | $2,115 | $4,230 | $8,460 | $11,280 |
* These Good Faith Estimate costs are valid for 12 months after received and signed.
Your Rights Under the No Surprises Act
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.
To dispute the bill, you should first 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 are unable to reach a reasonable agreement with the provider or facility, you may start a 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 about your right to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprises or call (800) 368-1019.
I have read and
understand this estimate.
I acknowledge receipt of this pricing schedule with good faith estimate and accept full responsibility for the payment of invoices for services rendered. I have read and agree to the above information in this Good Faith Estimate, understanding this document is not a contract for therapy services.
Keep a copy of this Good Faith Estimate in a safe place or take pictures of it.