Good Faith Estimate
FOR OUT-OF-NETWORK SERVICES FOR INSURED PERSONS AND/OR SELF-PAY CLIENTS
Good Faith Estimate Introduction
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 therapy 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 rendered to you that are not identified here.
DISCLAIMER: 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 sessions. The number of sessions that are appropriate in your case, and the estimated cost for those services, depends on your needs and what we agree to in consultation. You are entitled to disagree with any recommendations made to you concerning your treatment and you may discontinue treatment at any time.
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.
This 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.
Good Faith Estimate
This Good Faith Estimate is provided by SCOTT SPRADLIN, LPC, LMAC WISE MIND, WISE LIFE
Your provider will be SCOTT SPRADLIN, LPC, LMAC
Services will be provided via TELEHEALTH or IN-PERSON at 2400 N. WOODLAWN BLVD., #110, WICHITA, KS 67220 (ALL SERVICES ARE TELEHEALTH UNTIL FURTHER NOTICE).
Your anticipated services include one (1) INTAKE ASSESSMENT APPOINTMENT (CPT: 90791) with your provider, billed at a rate of $200.00 per SIXTY (60) MINUTE session, followed by recurring psychotherapy services. The fee for a 60–MINUTE PSYCHOTHERAPY session (CPT: 90837), in-person or via telehealth, with your provider is $200.00. Most clients attend at a frequency of: (a) one 60–MINUTE PSYCHOTHERAPY session per week.
The frequency of psychotherapy sessions that are appropriate in your case may be more or less, depending on your needs. Based on a fee of $200.00 Per CPT: 90837 session, the following are expected APPROXIMATE charges of psychotherapy services:
ESTIMATED ( NO MORE THAN) charges for one (1) 60-minute session per week PER STANDARD FEE:
4 sessions (approx. 4 weeks/1 month of services): $800.00
12 sessions (approx. 12 weeks/3 months of services): $2,400.00
26 sessions (approx. 26 weeks/6 months of services): $5,200.00
38 sessions (approx. 38 weeks/9 months of services): $7,600.00
52 sessions (approx. 52 weeks/12 months of services): $9,100.00
Other Potential/Estimated Fees and Charges
CPT: 90791 60 MINUTE SESSION INDIVIDUAL = $225.00
CPT: 90837 60 MINUTE SESSION INDIVIDUAL = $200.00
CPT: 90834 45 MINUTE SESSION INDIVIDUAL = $150.00
CPT: 90832 30 MINUTE SESSION INDIVIDUAL = $110.00
CPT: 90847 60 MINUTE SESSION FAMILY = $200.00
CPT: 90853 120 MINUTE SESSION GROUP = $70.00
LETTERS/REPORTS PREPARATION = $50.00 per 30 minutes increments
Example: $50.00 minimum, and $50.00 per 30 minutes increment as required.
For additional costs of other services, please view our Fee Schedule on the client portal or by visiting our website at: WWW.WISEMINDWISELIFE.COM
*Rates on the Fee Schedule are assessed periodically and may change. Any rate changes will be communicated via writing to current clients with at least 90 days’ notice prior to implementation.
Understanding This Notice and Estimate
If you have questions about this estimate, you can call our practice at 316.260.1127 or email us at SCOTT@WISEMINDWISELIFE.COM, or email@example.com.
Contact your health insurance to get more information about the true cost to you, if you have out-of-network benefits, or to get a list of in-network providers for your plan, if you choose to do so.
*For questions or more information about your right to a Good Faith Estimate or to start the dispute process, visit www.cms.gov/nosurprises or call 1-800-985-3059.
NOTE OF GOOD FAITH ESTIMATE: If you are billed IN EXCESS OF $400.00 more than this Good Faith Estimate, you have the right to dispute the bill. The above estimate was created on the date of consultation and is based on information known at the time the estimate was created. It does not include any unknown or unexpected costs that may arise during treatment.
DISPUTATION: You may contact your provider, SCOTT SPRADLIN, LPC, LMAC, Practice Owner, if your billed charges are $400.00 higher than this 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.
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.