No Insurance? - NOTICE OF YOUR RIGHT TO A GOOD FAITH ESTIMATE
January 1, 2022
New Leaf Counseling will make every effort to comply with this regulation. If you plan to pay for our services privately, without insurance assistance, please inform the office so that we can provide you with a Good Faith Estimate. Additionally, you will need to let us know how you would like to receive the estimate. (email, postal, fax address)
You have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost. Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services.
• You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees.
• Make sure your health care provider gives you a Good Faith Estimate in writing at least 1 business day before your medical service or item. You can also ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule an item or service.
• If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill.
• Make sure to save a copy or picture of your Good Faith Estimate.
For questions or more information about your right to a Good Faith Estimate, visit ww.cms.gov/nosurprises or call 618-980-2358.
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Insurance and Private Pay charges - session are at will
90791 Diagnostic Evaluation $195
90834 Individual Psychotherapy/45min $165
90837 Individual Psychotherapy/60min $185
90847 Family Therapy/ Conjoint Therapy $185
90846 Family Therapy without patient $185
90833 Psychotherapy additional 30 mins +$95
+99050 Evenings or weekends +$25
RRT Rapid Resolution Therapy 2-3 hr $600
RRT Follow-up $250
99003 No Show $75
99003 Late Cancel Charge $60