Good Faith Statement
Standard Notice: “Right to Receive a Good Faith Estimate of Expected Charged”Under the No Surprise Act
Dynamic Psychometrics LLC
Location: 13361 N 56th Street Office B Temple Terrace FL 33617 or Telehealth
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 email@example.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 $130
90846 Family (or conjoint) psychotherapy without the patient present $130
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.
F43.23 Adjustment Disorder
F32.9 Major Depressive Disorder
F41.1 Generalized Anxiety Disorder
F31.9 Bipolar Disorder
F25.9 Schizoaffective Disorder
F90.0 Attention Deficit Hyperactivity Disorder
F42.9 Obsessive Compulsive Disorder
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 $1,500
Comprehensive Autism Evaluation $2,000
Comprehensive ADHD Evaluation $1000 to $1300
Intellectual Disability $800 to $1000
Personality Assessment / basic psychodiagnostic $600
Surgical Readiness $750
Total estimated cost for evaluation will depend on the type of evaluation you choose.
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.