Good Faith Statement

Dynamic Psychometrics LLC

Location: 13361 N 56th Street Office B Temple Terrace FL 33617 or Telehealth

Phone: 727-279-5878 / email: info@d-psychometrics.com / web: https://www.d-psychometrics.com

Under Section 2799B-6 of the Public Health Service Act, health care providers and health care facilities are required to inform individuals who are not enrolled in a plan or coverage or a Federal health care program, or not seeking to file a claim with their plan or coverage or a Federal health care program, or not seeking to file a claim with their plan or coverage both orally and in writing of their ability, upon request or at the time of scheduling health care items and services, to receive a “Good Faith Estimate” of expected charges.

Brief explanation of estimate for new patients:

The estimate below is the range of costs that is likely for most patients in therapy. Therapy frequency will vary case by case depending on client’s need and treatment recommendation. Therapy is a voluntary process and frequency of sessions is a decision made between the client and the provider.

Highest level of frequency is once a week. Most commonly seen frequency is twice a month. If you are seen 2x a month for 1x year your cost for services will range $2,000 to $3,000 per year. The estimate below is the range of costs that we think is likely for the care of our clients.  However, depending on how treatment progresses, more or fewer sessions may be needed.

Contact: If you have questions about this estimate, please contact Dynamic Psychometrics LLC at 727-279-5878 and info@d-psychometrics.com.

Details of the Estimate

The following is a detailed list of expected charges for therapy services.

Most common therapy services and fees

• 90791 Mental health diagnostic evaluation $100 to 160
• 90837 Psychotherapy, 53-60 minutes with patient and/or family member $120 to 130
• 90834 Psychotherapy, 38-53 minutes with patient and/or family member $100 to 110
• 90832 Psychotherapy, 16-37 minutes with patient and/or family member $90
• 90847  Family (or conjoint) psychotherapy with the patient present $150
• 90846 Family (or conjoint) psychotherapy without the patient present $150

Listed below are common diagnosis codes seen by the providers in this office.

Please note these are common diagnosis codes in psychotherapy but this list is not exhaustive. Diagnosis codes can change based on many factors. Please speak with your therapist with any questions or concerns.

The estimated costs are valid for 12 months from the date of this Good Faith Estimate, unless we send you an updated estimate. You may ask for an updated estimate as well.

Total estimated cost for therapy: $3,000 to $5,000 a year.

The following is a list of most common psychological evaluation performed at our office and their costs.

• Comprehensive Psychoeducational Assessment $1,760
• Comprehensive Autism Evaluation $2,010
• Comprehensive ADHD Evaluation $1000 to $1300
• Intellectual Disability $750 to $1000
• Personality Assessment / basic psychodiagnostic $700
• Surgical Readiness $700
• Immigration $800+

Total estimated cost for evaluation will depend on the type of evaluation you choose.

Disclaimer

This Good Faith Estimate shows the costs of services that are reasonably expected for the expected services to address your mental health care needs. The estimate is based on the information known to us when we did the estimate.

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 $400 more (per provider) than this Good Faith Estimate (GFE), you have the right to dispute the bill

You may contact the psychology practice at the contact listed above to let them know the billed charges are at least $400 higher than the GFE. You can ask them to update the bill to match the GFE, 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 GFE. 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 CMS at 1-800-985-3059.

For questions or more information about your right to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprises or call CMS at 1-800-985-3059 .

This GFE is not a contract.  It does not obligate you to accept the services listed above.

Keep a copy of this Good Faith Estimate (GFE) in a safe place or take pictures of it. You may need it if you are billed more than $400 than the estimate provided above.