Good Faith Estimate
When you start services with us and choose to pay out-of-pocket, you will receive a document that looks like this, but with your information in the relevant categories. 

Date of Good Faith Estimate:

Client information:

Name:

Date of Birth:

Client Services and Diagnosis:

Primary Service Requested/Scheduled and Service code:

Primary Diagnosis and Code (if known):

Secondary Diagnosis and Code (if known):

If scheduled, date(s) the service will be provided:

Provider/Facility Information:

Facility Name: Summit Psychotherapy, PLLC

Provider Name & NPI: Hillary Sunderland 1063705168

Provider Name & NPI: Casey Donohoe 1598428567

Provider Name & NPI: Stefanie Kremer 1596701392

Provider Name & NPI: Elizabeth Imhoff 1962274399

Provider Name & NPI: Erin Rupert 1639883721

 

Provider EIN/TIN: 86-3769861

Facility Physical Address: 330 Fiedler Ave. Suite 207, Dillon, CO 80435

Expected Charges:

The following is a list of expected charges.  The estimated costs are valid for 12 months from the date of the Good Faith Estimate.

Service/Item: Psychotherapy

Address where service/item will be provided: Dependent on Location of Provider

Diagnosis Code:

 

 

Psychotherapy Session

Provider Type

Self-Pay Rates

Fully Licensed (LCSW, LPC)

120-150

Provisionally Licensed (LSW, LPCC)

75-120

Masters Intern

50-75

 

Service Codes: 90832, 90834, or 90837

Quantity:

Expected Cost: See table above

Additional Provider Notes Including Total Estimated Cost: If a client chooses to bill insurance, the rate, applicable co-pays, co-insurance or deductible are set by the insurance company.  You will be expected to pay any applicable co-pay, co-insurance or deductible at time of service.  Please contact your insurance for further information on what you may owe.

 

 

Disclaimers

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 and is subject to change.

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. 

The Good Faith Estimate is not a contract and does not require you to obtain the services from the provider identified on the Good Faith Estimate.

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.