Good Faith Estimate
Rendering Provider: Amanda Proctor Abbott, Psy.D.
Billing Provider: Proctor Psychology, PLLC
Group NPI #: 1568223717
Health care providers and health care facilities are required to provide a Good Faith Estimate both orally and in writing of expected charges for items and services provided to 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, upon request or at the time of scheduling health care items and services.
This Good Faith Estimate is not intended to serve as a recommendation for treatment or a prediction that you may need to attend a specified number of psychotherapy visits. The number of visits that are appropriate in your case, and the estimated cost for those services, depends on your need and what you agree to in consultation with your psychologist. You are entitled to disagree with any recommendations made to you concerning your treatment and you may discontinue treatment at any time. Also, please note that this Good Faith Estimate does not include non-medical costs of service that may incur over the course of psychotherapy.
Psychotherapy treatment usually begins with weekly sessions for preferably 6 consecutive weeks. You and your provider will continually assess the appropriate frequency of therapy sessions and the plan for treatment titration or discharge. Duration of treatment typically lasts 3-6 months, however, the frequency and length of psychotherapy visits may be more or less depending on the following factors: individual needs/preferences, schedule and life circumstances, therapist availability, the nature of your specific life challenges and how you address them, and personal finances.
A new Good Faith Estimate can be issued should the frequency of session(s) or needs change. As related, you may request a new Good Faith Estimate at any time in writing during your treatment.
GOOD FAITH ESTIMATE PER TREATMENT MODALITY (SELECT AT LEAST ONE)
☐ INDIVIDUAL PSYCHOTHERAPY (90837 = 50-60 minutes = $200/HR)
⮚ Total Estimated Charges for 6 initial sessions = $1,200; for 12 sessions (3-4 months of service) = $2,400; for 24 sessions (6-8 months of service) = $4,800
⮚ Total Estimated Charges for 90837 Plus Evening/Holiday Surcharge (99050 = $25/HR) for Initial 6 Sessions = $1,350; for 12 sessions (3-4 months of service) = $2,700; for 24 sessions (6-8 months of service) = $5,400
⮚ Total Estimated Charges for 90 minute session (90834x2) = $320 for initial 6 sessions = $1,920; for 12 sessions (3-4 months of service) = $3,840; for 24 sessions (6- 8 months of service) = $7,680
☐ COUPLES, CHILD/ADOLESCENT & FAMILY PSYCHOTHERAPY (90837 + 90785) = 50-60 minutes = $230/HR)
⮚ Total Estimated Charges for 6 initial sessions = $1,380; for 12 sessions (3-4 months of service) = $2,760; for 24 sessions (6-8 months of service) = $5,520
⮚ Total Estimated Charges for 90837 + 90785 Plus Evening/Holiday Surcharge (99050 = $25/HR) for Initial 6 Sessions = $1,530; for 12 sessions (3-4 months of service) = $3,060; for 24 sessions (6-8 months of service) = $6,120
⮚ Total Estimated Charges for 90 minute session ((90834+90785)x2) = $365 for Initial 6 Sessions = $2,190; for 12 sessions (3-4 months of service) = $4,380; for 24 sessions (6-8 months of service) = $8,760
☐ BRIEF PSYCHOLOGICAL EVALUATION
⮚ BRIEF PSYCHOLOGICAL EVALUATION (Clinical Interview, MMPI-3, and Integrated Written Report) = (90791 + 96103 + 96130 + 96131) = $500
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. 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 bills that exceed the estimate by more than $400. Thus, if you are billed for more than $400 above this Good Faith Estimate, you have the right to dispute the bill.
To dispute the bill, you should first 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. If you are unable to reach a reasonable agreement with the provider or facility, you may 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.
**These Good Faith Estimate costs are valid for 12 months.**
To learn more about your right to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprises or call (800) 368-1019.
I acknowledge receipt of this pricing schedule with Good Faith Estimate and accept full responsibility for the payment of invoices for services rendered. I have read and agree to the above information in this Good Faith Estimate, understanding this document is not a contract for therapy services.
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