GOOD FAITH ESTIMATE FOR HEALTH CARE ITEMS AND SERVICES , AND REQUIRED NOTICE OF "NO SURPRISES ACT"

Diagnosis: Cannot be rendered without meeting with client for current evaluation. Diagnosis below only used to generate good faith estimate - and other clinical documentation will be updated as appropriate after 1-2 sessions of a diagnostic evaluation. Clinician's Name and NPI: AnnaMarie Pemberton, LCPC, PMH-C NPI: 1891234852 Diagnosis: Z65.9 Unspecified Problems related to Unspecified Psychosocial Circumstances According to your benefit verification, the tentative Out of Pocket costs are as follows if coverage is denied resulting in private pay sessions - Total costs could be anticipated to be the following: $200 for Diagnostic Evaluation 90791 - $175 for Ongoing Psychotherapy 90837 Yearly Service Code Estimates: Diagnostic Evaluation 90791 = 1-2x yearly; AND Ongoing Psychotherapy appointments 48 weeks yearly Yearly Cost Estimates for Private Pay Rates: $8425.00 The above is a detailed list of expected charges. The estimated costs are valid for 12 months from the date of f the Good Faith Estimate. Treatment will be re-evaluated at minimum every 6 months and GFE can be updated and provided. DISCLAIMER 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. It is possible that you may be recommended additional or different treatment options to better meet your care needs. Your Good Faith Estimate may change based on clinical needs, medical necessity, or clinical recommendations. 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 A SIGNIFICANT AMOUNT 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.

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