Good Faith Estimate

The following is information concerning fee schedules and payment procedures. 

   Phone Consultation  FREE  (15 minutes)

   Intake Session $200.00 (60 minutes) 

   Individual Session $175.00 (50 minutes)

   Telephone Consultation $35 (billed at 10 minute increments) 

   Consultation with Collaborating Providers $35 (billed at 10 minute increments) 

   Collateral Services $35* (billed at 10 minute increments) 

Payment is due at the completion of the session. You are required to keep a valid credit card on file. Payments can be made by debit or credit card. We accept Visa, Mastercard, American Express, Discover and HSA cards. 

Your card will be charged after each session or consultation. 

Your card will automatically be charged $150.00 for a missed appointment (no show or cancellation with less than 48 hours notice prior). 

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. Depending on the progress we make, I expect that we will have continuous weekly or bi-weekly therapy sessions for the next 6-12 months at our agreed upon rate. 

HEALTH INSURANCE WAIVER 

As discussed (verbally or via email), you understand that I do not accept insurance as a method of payment. By using these services, you understand you are waiving the usage of your insurance. You are, however, more than welcome to use your HSA/FSA accounts for payment.

If requested, you will be provided with a statement on the 10th of every month. This statement will include Dates of Service, Billing Codes, and Diagnostic Codes (if applicable). You may choose to submit these statements to your insurance company in an effort to request full or partial reimbursement. *Telephone consultations are generally not reimbursable by insurance. 

Provider Information 

Provider Name: Joan Phillips 

Provider/facility type: Virtual or Office 

Business mailing address: 11 rugby Road Merrick, NY 11566

Phone: 516-236-3922 

Email: joan@joanphillipspsych.com

Provider NPI: 1780204727

Taxpayer Identification Number (TIN): 82-3309527 

Details of Services, Frequency, and Charges 

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 rendered 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. 

ADDITIONAL FEES: There may be additional fees that occur in the course of your treatment that are outside the scope of this estimate and will be billed at the rate outlined in the practice policies document. This includes: court and legal fees, on/off site consultations, written reports, review of records and to any telephone conversations lasting over 15 minutes, including travel time for off-site services. Clients will be notified of these charges prior to the services being rendered. 

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. 

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 HHS at (800) 368- 1019. 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) 368-1019. 

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. 

Your signature on this GFE indicates that the reimbursement decision is that solely of your insurance provider and your therapist in no way guarantees or has authority in this reimbursement decision. 

I acknowledge that I have read the information included, have had an opportunity to ask questions, and I agree to engage in the service(s) listed. I consent to sharing information provided here. 

Client Signature 

Representative Signature (if applicable) 

Date