Good Faith Estimate

This is provided to you the client as a good faith estimate of cost for services provided by Heidi Kolman, LCSW.  You will be entering into a psychotherapy treatment using individual sessions.  This form will serve  as an estimate of cost per service received. (i.e. cost per session)

It will be discussed between therapist and client  as to length of sessions as well as frequency of sessions.

 

 

Service Expected:  Individual psychotherapy sessions  to be billed at 90834 or 90837

Price per service: 

Diagnosis

 

If insurance will be used,  please contact your insurance company to assess copays and deductibles for your plan.  You are responsible for all copays and deductible charges.

 

 

During the course of therapy,  Treatment Plan and goals can change.  As this occurs a new Good Faith Estimate will be provided to you.

 

You have the right to dispute bills that are higher than this estimate.  Please contact the provider to do so.