Good Faith Estimate

In compliance with the No Surprises Act that went into effect January 1, 2022, all healthcare providers are required to notify clients of their Federal rights and protections against “surprise billing.”

This Act requires that we notify you of your federally protected rights to receive a notification when services are rendered by an out-of-network provider, if a client is uninsured, or if a client elects not to use their insurance.

Additionally, we are required to provide you with a Good Faith Estimate of the cost of services (see below). It is difficult to determine the true length of treatment for mental health care, and each client has a right to decide how long they would like to participate in mental health care. Therefore, below you will find a fee schedule for the services typically offered by your provider, and NOVA PS will collaborate with you on a regular basis to determine how many sessions you may need.

Your estimated total cost: TBD

See the itemized fee schedule below for more detail about what can be estimated for your total cost for services.

It is your ethical right to determine your goals for treatment and how long you would like to remain in therapy unless you are in mandatory treatment. Services generally recur on a weekly basis until which time treatment goals are met.

Your provider will collaborate with you throughout your treatment to determine how many sessions and/or additional services you may need to receive the greatest benefit based on your diagnosis(es)/presenting clinical concerns.

Details of Services and Items for NOVA Psychological Services

90791 Initial Diagnostic Evaluation $350
90837 Psychotherapy, 60 min $280
90834 Psychotherapy, 45 min $210
90832 Psychotherapy, 30 min $140
90839 Psychotherapy for a Crisis, 60 min $280
+90840 Psychotherapy for a Crisis, 30 min add-on $140
90846 Family therapy w/o Patient, 45 min $210
90846 Family therapy w/o Patient, 60 min $280
90846 Family therapy w/o Patient, 45 min $210
90847 Family therapy with Patient, 60 min $280
98966-68 Telephone Assessment & Management--Prorated hourly rate ($70/quarter hour)
98970-72 Online Digital Evaluation & Mgt (email/text response)--Prorated hourly rate ($70/quarter hour)
Cancellation Fee: you are responsible for the full fee of an appointment missed without 24-hr notice
Reports: Dependent on time required for completion (<15 min free; prorated $70/quarter hour)
Legal Fees $350/hour ($2800 retainer)

Place of Service (in office vs. telehealth) is not delineated above since the charges are identical.

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, and does not include any unknown or unexpected costs that may arise during treatment.

The Good Faith Estimate is not a contract between provider and client and does not obligate or require the client to obtain any of the listed services from the provider.

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.

Throughout your treatment, the provider may recommend additional items or services as part of your treatment that are not reflected in this estimate. These would need to be scheduled separately with your consent and the understanding that any additional service costs are in addition to the Good Faith Estimate.

If your needs change during treatment, your provider should supply a new, updated Good Faith Estimate to reflect the changes to treatment, and the accompanying cost changes.

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.

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 or take pictures of it. You may need it if you are billed a higher amount.

It is a Federal requirement that we have each client sign this form to begin/resume treatment.

Thank you very much,

NOVA Psychological Services, LLC