Good Faith Estimate for Health Care Items and Services
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. Please read this if this applies to you.
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 http://www.cms.gov/nosurprises.
Chesapeake Counseling Center
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 cancellation/no show fees, crisis sessions, non-therapeutic charges e.g. documentation fees, banking fees, court/litigation fees or other financial arrangements based on a case-by-case basis. See ‘Practice Policies, Disclosure, and Financial Responsibility’ for complete details regarding this fee schedule.
90791 ~ Intake Session – Individuals/Couples/Families 55 minutes – $175.00
90832 ~ Individual Psychotherapy, 30 – 44 minutes – $75.00
90834 ~ Individual Psychotherapy, 45 – 52 minutes – $125.00
90837 ~ Individual Psychotherapy, 53 – 60 minutes – $150.00
90839 ~ Psychotherapy Crisis, 60 minutes – $175.00
90840 ~ Additional Psychotherapy Crisis, 30 minutes – $125.00
90846 ~ Family Psychotherapy, conjoint psychotherapy w/o patient present 50 minutes – $150.00
90847 ~ Family Psychotherapy, conjoint psychotherapy w/ patient present 50 minutes – $150.00
90853 ~ Group Therapy, 75 – 80 minutes – $50.00
Charge Backs – $30.00
Non-sufficient funds (NSF) – $30.00
Documentation Fee – $50.00
Cancellation Fee (less than 24 hour notice) $50
Chesapeake Counseling Center estimated total for weekly/bi-weekly/monthly psychotherapy sessions:
Individual Weekly Session Fee: $150.00
Couple/Family Weekly Session Fee: $150.00
Total estimated psychotherapy cost: Individual Annual Session Fee: Maximum $7950.00* (based on 52weeks x $150.00+150.00 = $7950)
Length of Services
Psychotherapy services can range from two days, 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 your therapist at Chesapeake Counseling Center 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, Chesapeake Counseling Center will discuss your options with you at which time a new Good Faith Estimate will be created, your therapeutic services will end, or you will be referred to another provider.
The above listed total estimated psychotherapy cost is based on a 52 week structure at the individual rate of $150.00 per one session a week and intake fee of $175.00 equating to $7950.00; and the couples/families rate of $150.00 per one session a week and intake fee of $175.00 equating to $7975.00. These totals DO NOT account for no show/late cancelation fees, bank charges, crisis sessions, non-therapeutic charges e.g. documentation fees, banking fees, court/litigation fees or other financial arrangements based on a case-by-case basis. You are encouraged to carefully read the ‘Practice Policies, Disclosure, and Financial Responsibility’ for complete details regarding fee schedule.