Good Faith Estimate

Effective January 1, 2022, a ruling went into effect called the "No Surprises Act" which requires practitioners to provide a "Good Faith Estimate" about out-of-network care. The Good Faith Estimate works to show the cost of items and services that are reasonably expected for your health care needs for an item or service, a diagnosis, and a reason for therapy. The estimate is based on information known at the time the estimate was created. 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 and will be provided a new "Good Faith Estimate" should this occur. If this happens, federal law allows you to dispute (appeal) the bill if you and your therapist have not previously talked about the change and you have not been given an updated good faith estimate. 

Under Section 2799B-6 of the Public Health Service Act (PHSA), health care providers and healthcare 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 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. Note: The PHSA and GFE does not currently apply to clients who are using insurance benefits, including "out of network benefits'' (i.e., submitting superbills to insurance for reimbursement). 

Timeline requirements: Practitioners are required to provide a good faith estimate of expected charges for a scheduled or requested service, including items or services that are reasonably expected to be provided in conjunction with such scheduled or requested item or service. That estimate must be provided within specified timeframes:

- If the service is scheduled at least three business days before the appointment date, no later than one business day after the date of scheduling; 

- If the service is scheduled at least 10 business days before the appointment date, no later than three business days after the date of scheduling;

 - If the uninsured or self-pay patient requests a good faith estimate (without scheduling the service), no later than three business days after the date of the request.

A new good faith estimate must be provided, within the specified timeframes if the client reschedules the requested item or service. 

Common Services at Peace of Mind Counseling Services, PLLC

- 90791: Initial therapy intake 

- 90834/90837: Ongoing therapy appointments

- 90847: Couples' appointments 

Common Diagnosis Codes at Peace of Mind Counseling Services, PLLC:

Below are common diagnosis codes at 

Peace of Mind Counseling Services, PLLC; 

however, the list is not exhaustive. With that said, diagnosis codes can change based on many factors. Please speak to your therapist with any questions or concerns. 

Adjustment Disorder (F43.23, F43.22, F43.20), 

Depression (F32.9) Anxiety (F41.1, F41.9), PTSD/

Post Traumatic Stress Disorder (F43.10).

Peace of Mind Counseling Services, PLLC recognizes every client's therapy journey is unique. How long you need to engage in therapy and how often you attend sessions will be influenced by many factors including: 

- Your schedule and life circumstances

- Therapist availability

- Ongoing life challenges 

- The nature of your specific challenges and how you address them

- Personal finances 

You and your therapist will continually assess the appropriate frequency of therapy and will work together to determine when you have met your goals and are ready for discharge and/or a new "Good Faith Estimate" will be issued should your frequency or needs change.

Where services will be delivered: 

Peace of Mind Counseling Services, PLLC is a telehealth and in-person solo private practice; as such, all benefits will be quoted as virtual/in-person.

Peace of Mind Counseling Services, PLLC is located at 

3800 Highway 365, Suite 141, Port Arthur, Texas 77642

Clinician available at Peace of Mind Counseling Services, PLLC

(Dr. Nicky Underwood, DSW, LCSW-S, NPI 1 1245770197 

and EIN 844080288)

Client Info: (completed by the client)

Please enter your information below. 

First Name: ______________________________

Middle Initial: _______

Last Name:______________________________

Date of Birth:_____________________________

Mailing Address: ___________________________

Phone Number: ____________________________

Email Address:_____________________________

Client Diagnosis: ___________________________

At Peace of Mind Counseling Services, PLLC, we must diagnose all clients for both ethical, legal, and insurance reasons -- as well as required by the "No Surprises Act".

Your Good Faith Estimate Diagnosis is:

- Primary Diagnosis: Z73.3 

- Stress not elsewhere specified 

- Secondary Diagnosis: F99 

- Mental Health Disorder, Not Otherwise Specified 

This diagnosis is only to satisfy the federal requirement for this form. 

This is not a formal psychological diagnosis. A formal diagnosis occurs after an assessment has been completed. That will take place 1-5 sessions after beginning psychotherapy. 

If you choose to decline a formal diagnosis, we will not update this GFE. It is within your rights to decline a diagnosis per state and federal guidelines. 

Primary Service or Item Requested/Scheduled (please check one) 

____Individual Therapy (20+)

____Couples Therapy (20+)

____Group Therapy (20+)

Your Financial Responsibility Summary

For a good faith estimate: the amount you would owe if you were to attend therapy for 52 sessions in a year (weekly, without skipping any weeks for holidays, break, vacation, unplanned events/sickness, etc.). The "Good Faith Estimate" requires practitioners to provide an exact estimate and not a range.

Out of an abundance of caution and transparency, we will only quote weekly appointments. 

Your Annual Cost Estimate: (to be completed by the therapist) 

___________________________________________ 

 Annual Estimate for weekly sessions 

_________________________

Date of Estimate

 ___________

Good Faith Estimate Disclaimer

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.

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 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 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 800-985-3059. Keep a copy of this Good Faith Estimate in a safe place.

__________________________________  _________________

•                       Client Signature                              Date