Good Faith estimate

 Good Faith Estimate

Provider: Paula Soto, LCSW, ERYT, YACEP

NPI:     1568598258       TIN: 45-5453150

Physical Location: 250 Insurance Street, Suite 203, Beaver, PA 15009

Alternate Location: POS 10 or 02 for telehealth

Common Diagnosis Codes: Below are common diagnosis codes; however, the list is not exhaustive. With that said, diagnosis codes can change based on many factors. Please let me know if you have any questions or concerns.

• Adjustment Disorder (F43.23)
• Bipolar Disorder (F31.9)
• Social Anxiety Disorder (F40.10)
• PTSD (F43.10)
• Depression (F32.0-F33.3)
• Generalized Anxiety Disorder (F41.1)
• Reaction to Severe Stress, Unspecified (F43.9)
• Other Reactions to Severe Stress (F43.89)

Paula Soto recognizes that every client's therapy experience is unique. How long you need to engage in therapy and how often you attend sessions will be influenced by many factors including:

• Your schedule, availability, and life circumstances
• Therapist availability
• Ongoing life challenges (may increase or decrease frequency of sessions)
• The nature of your specific challenges and how you address them
• Personal finances

Together we will continually assess the appropriate frequency of therapy and will work to determine when you have met your goals and are ready for discharge.

Where services will be delivered. 

• Services are being provided in the office, or virtual – depending on the current public health situation and client choice. (See physical office address above.)
• Trauma Focused Intensives can be provided in a retreat location that is mutually agreed upon by client and therapist.  

Client Information

This Good Faith Estimate is specifically tailored for:

Name: SAMPLE

Date of Birth: N/A

2

Client’s Contact Preference:

☐ by postal mail  ☐ electronically  ☐ in person pick up

Client Diagnosis

As a therapist, I must diagnose clients for legal, and insurance reasons -- as well as required by the "No Surprises Act."

Your initial Good Faith Estimate diagnosis will be:

Z13.30 Encounter for screening for mental health diagnosis

This diagnosis is only to satisfy the federal requirement for this form and is not a formal psychological diagnosis. A formal diagnosis occurs after an assessment has been completed, which typically occurs 1-5 sessions after beginning psychotherapy. If you choose to decline a formal diagnosis, I will not update this GFE.

It is within your rights to decline a diagnosis per state and federal guidelines. 

5

Your Financial Responsibility Summary

For a good faith estimate: the amount you would owe if you were to attend therapy for 48 sessions (of 53 minutes each) in a year (weekly, skipping for holidays etc.) - multiply 90791/90837 rate by 48. The "Good Faith Estimate" requires practitioners to provide an exact estimate and not a range.

Out of an abundance of caution and transparency, I will only quote weekly appointments.

Service

Billing Code

Provider Charge

Your rate (based on discussion of need for sliding scale)

Intake

90791

165.00

TBD

Weekly Individual Therapy 53+ minutes

90837

165.00

TBD

Individual Therapy 38-52 minutes

90834

115.00

TBD

Individual Therapy 16-37 minutes

90832

75.00

TBD

Family without patient

90846

165.00

TBD

Family with patient

90847

165.00

TBD

Extended Session 75-80 minutes

240.00

TBD

Intensive - per hour rate, Beaver, PA Office

225.00

*Sliding Scale and Intensive rates are detailed in the intake consent form and on the website.

*EMDR Intensives (EMDR therapy provided over the course of one or more days) are developed specific to the client; rates depend on the number of days/hours per day dedicated to therapy. Client travel and lodging costs are not included in the intensive rate. Rates for off-site intensives are calculated on a case by case basis.  An individualized GFE will be furnished to Intensive clients.

Good Faith Estimate Disclaimers:

• 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. 
• The Good Faith Estimate does not include services not provided by your provider that you may need and that your provider may recommend. For instance, the Good Faith Estimate does not include the cost of seeking medication for mental health.
• The Good Faith Estimate is an estimate for services only and does not include other fees, such as fees for canceling less than 48 hours in advance of a scheduled appointment. These fees are outlined in the informed consent that is signed before the start of therapy services.
• This Good Faith Estimate is not a contract and does not obligate you to receive the services listed nor does it obligate you to receive the services listed by this provider.
• 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. 
• You may also 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 and get a form to start the process, go to www.cms.gov/nosurprises or call 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 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.