You have the right to receive a “Good Faith Estimate” explaining how much your medical/mental health 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 one (1) business day before your medical service or item. You can also ask your healthcare 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 www.cms.gov/nosurprises.
Insurance Opt-out/Acknowledgement of No Insurance: I acknowledge my provider doesn't accept insurance, I don’t have insurance or I am opting out of using my insurance.
Details of Services and Items for T&M Wellness
The following is a detailed list of expected charges. The estimated costs are valid for 12 months from the date of the Good Faith Estimate. Provider Estimates - *Maximum does not include late cancelation/no show fees, crisis sessions, non-therapeutic charges e.g. documentation fees, banking fees, court/litigation fees, phone call fees, or other financial arrangements based on a case-by-case basis. See 'Practice Policies’ for complete details regarding this fee schedule.
Psychotherapy: Initial Consultation to determine if T&M Wellness services are right for you 20 minutes - $0.00. Telehealth Session - Individual/relational/family 50 minutes - $150.00. Telehealth Session - Individual/relational/family 90 minutes - $245.00. This rate will be prorated based on $150 per hour. Service charge for returned checks, for any reason - $20.
WEEKLY Sessions - T&M Wellness total estimated psychotherapy maximum cost based on 52 weeks*: 50-minute weekly telehealth $7,800 (based on 52 weeks x $150.00).
BI-WEEKLY Sessions - T&M Wellness total estimated psychotherapy maximum cost based on 26 weeks*: 50-minute bi-weekly telehealth $3,900 (based on 26 weeks x $150.00).
MONTHLY Sessions - T&M Wellness total estimated psychotherapy maximum cost based on 12 months*: 50-minute monthly telehealth $1,800 (based on 12 months x $150.00).
Length of Services
Psychotherapy services can range from one day, to two months, to a year or more. The length of time you will need to be in therapy is based on your therapeutic goals, your overall wants and needs, and any psychosocial/financial barriers that may arise. With this being said, communication is key to any healthy relationship. Should a financial hardship occur, you are encouraged to discuss your situation with T&M Wellness to determine the best resolution as it pertains to your continuity of care and the therapeutic relationship. Should more time be required to meet your therapeutic goals, T&M Wellness will discuss your options with you at which time a new Good Faith Estimate will be created, your therapeutic services will end, or you are referred to another provider. The above listed total estimated psychotherapy cost is based on a 52-week structure, 26-week structure, or monthly structure.
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.
Please see "Details of Services and Items for T&M Wellness" above. Please review the 'Practice Policies' (current clients) for the complete details regarding T&M Wellness fee schedule. *Maximum does not include late cancellation/no show fees, crisis sessions, non-therapeutic charges e.g. documentation fees, banking fees, court/litigation fees, phone call fees, or other financial arrangements based on a case-by-case basis.
Provider Name: T&M Wellness. Mailing Address: 4516 South 700 East, Salt Lake City, Utah 84117. Contact person: Tiffani Pestotnik. Phone: 801.647.5593 Email: firstname.lastname@example.org National Provider Identifier (NPI): 1588916779. Taxpayer Identification Nuber (TIN): 86-372720