The following is a sample Good Faith Estimate.
Provider
| Mark Voss, LPCC |
| 2105 Vista Oeste NW, Suite E #3102, Albuquerque, NM 87120 |
| Tel: (505) 437-0125 |
| TIN: — |
Client
| Client Name: John Smith |
| Client Address: 123 Happy Lane, Goodtown, NM, 80000 |
| Client Phone #: 505 555-5555 |
| Primary Diagnosis (if applicable; to be completed by therapist): Currently, “Stress not elsewhere classified” Diagnosis code: Z73.3 |
| Secondary Diagnosis (if applicable; to be completed by therapist): — Diagnosis code: — |
By law, you are entitled to receive this “Good Faith Estimate” (GFE) of possible charges for psychotherapy services provided to you. This estimate is intended for clients who (1) do not have, or (2) do not intend to file an insurance claim for counseling services, in order to avoid any surprises in costs of service.
Diagnosis
The diagnosis section of the form above is required under the No Surprises Act. The code Z03.89, “Stress not elsewhere classified” is used as a placeholder diagnosis and will be updated if/when necessary. In general, diagnoses are required by insurance companies, but as a self-pay client it is your choice whether to receive one. Mental health diagnoses have benefits as well as risks, and some studies have questioned their accuracy, validity, and utility.
An Estimate in Good Faith
- It is not possible to know, in advance of meeting and beginning the work, how many counseling sessions may be necessary or appropriate for a given person.
- In order to reduce paperwork, below is an estimate of the cost for one full year of continuous, weekly service. This portrays the higher end of cost, not what you must necessarily expect.
- This GFE is not a contract, does not obligate you to obtain any services from the provider listed, and does not serve as a recommendation 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.
- This estimate is valid for 12 months from the date of the GFE or until it is updated with new information about expected length of treatment and cost.
- This estimate reflects only mental-health related counseling sessions. Additional offerings that you might avail yourself of, such as workshops, online courses, yoga and meditation classes, etc., are outside the scope of this Good Faith Estimate.
| Date(s) of Service | Description | Service Code | Estimated amount to be paid at time of service |
| Weekly, starting: | Weekly sessions for one year (50 weeks) | 90834, Individual psychotherapy | $140 per 50-minute session |
| Total estimate of what you may owe: | $7000* | ||
| Provider signature: | Date: |
*Note: Many clients find substantial help within a range of 10 to 20 sessions, over a 3–6-month period. The range of cost in that case is therefore $1400 – $2800. Some clients begin counseling by meeting weekly (and more rarely, twice a week), and then transition to biweekly or even monthly sessions. Some also do less than 10 sessions; it depends on you, your needs and goals, and the results we find together.
Disclaimer
This Good Faith Estimate shows the cost of services that are reasonably expected for counseling for the given length of time (52 weeks). The estimate is based on information known at the time the estimate was created and does not include any unknown or unexpected costs that may arise during treatment.
Throughout your treatment, the provider may recommend additional items or services as part of your treatment that are not reflected in this estimate. These would need to be scheduled separately with your consent and the understanding that any additional service costs are in addition to the Good Faith Estimate.
If you are billed for more than this Good Faith Estimate, you have the right to dispute the bill.
Visit the No Surprises Act page at www.cms.gov or call (800) 985-3059 for more information.
If you decide to initiate a dispute resolution process, it will not adversely affect your quality of care. However you are encouraged to speak with your provider at any time about any questions you may have regarding your treatment, your billing, or the information provided to you in this Good Faith Estimate.