Good Faith Estimate for Individuals Paying "Out of Pocket" (self-pay)

This Good Faith Estimate shows the cost of services that are reasonably expected for your health care needs between January 1, 2022 - December 31, 2022.

Appointment Fees:  $250 per appointment

Frequency of Appointments:

At the beginning of a course of Talk Therapy treatment, sessions will be held once weekly.  Over time, as insight into the nature of the problem is gained, and strategies for managing the problem are learned, the frequency of the sessions may diminish. Eventually they may no longer be needed on a regular basis.  Once therapy has concluded, occasional "booster sessions" may be recommended.  It is recommended that follow-up appointments are scheduled during appointments 

The frequency of medication management follow-up appointments is, at a minimum, once every other month (i.e., every 2 months).  We will meet more often as clinically indicated and recommended by Dr. Rambo.

Fee for Late Cancellations (cancelled with less than 48 hours notice) and Missed Appointments:  $250

Prescription Refill(s) requested between Scheduled Appointments due to a Missed/Postponed/Rescheduled Appointments:  $25

 

Additional Fees may apply for Other Services (such as completion of forms):  $25 per 15 minutes

For the initial appointment, an invoice will be provided (and payment is due) prior to the initial meeting.  For subsequent appointments, invoices shall be past due if payment is not received by the 10th of the following month.  Past due balances shall accrue interest at the rate of 1.5% per month.

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 US 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 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, you will have to pay the higher amount.    There is no penalty for overestimated charges.  

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.