Good Faith Estimate
You have the right to receive a Good Faith Estimate explaining how much your care will cost.
Under the federal No Surprises Act, health care providers must give people who are uninsured, or who are not using insurance, an estimate of the expected charges for medical items and services, including psychotherapy.
Who this applies to
Heart Space Clinical Psychology is a private pay, out of network practice and does not bill insurance directly. If you are uninsured, or you are insured but do not plan to submit claims through your health plan for these services, you are entitled to a Good Faith Estimate before your care begins.
What you are entitled to
- A written estimate, in a way you can save and print, of the total expected cost of any non-emergency items or services.
- An estimate on request, for any item or service, before you schedule.
- An estimate automatically once you schedule, within the timelines below.
- To ask any question about the estimate and to have it explained to you.
When you will receive it
- If you schedule at least ten business days in advance, within three business days of scheduling.
- If you schedule between three and nine business days in advance, within one business day of scheduling.
- If you ask for an estimate without scheduling, within three business days of your request.
Current fees
These are the standard fees for the practice. Your own estimate will be based on the services you and Dr. Pancholi-Patel expect to use, and on how often you expect to meet.
| Service | Fee |
|---|---|
| Initial consultation, 15 minutes | No charge |
| Initial therapy session | $275 |
| Follow-up individual therapy session | $250 |
| Couples or family session | $300 |
| Clinical supervision | Rate available upon inquiry |
Because psychotherapy is ongoing, an estimate usually covers a defined period, for example twelve months of weekly sessions, and states the assumed number of sessions. The number of sessions you actually need is a clinical question that is revisited with you over time.
What the estimate is, and what it is not
A Good Faith Estimate shows the costs of items and services that are reasonably expected for your care. The estimate is based on the information known at the time it is created, and it does not include any unknown or unexpected costs that may arise during treatment. It is an estimate, not a contract, and it does not obligate you to obtain the services listed.
If you are billed more than your estimate
If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill. You must start the dispute process within 120 calendar days of the date on your bill. There is a $25 fee to use the dispute process. If the reviewing entity agrees with you, you will pay the price on the estimate. If it agrees with the provider, you will pay the higher amount.
To learn more, or to start a dispute, visit cms.gov/nosurprises or call 1-800-985-3059.
Requesting your estimate
To request a Good Faith Estimate before scheduling, contact the practice at hello@heartspaceclinicalpsychology.com or (571) 384-8823.
Keep a copy of your Good Faith Estimate in a safe place. You may need it if you are billed more than the estimated amount.