NO SURPRISES ACT/ GOOD FAITH ESTIMATE
FOR PSYCHOTHERAPY
Jennifer Finch, M.A., LPC, ACS, NCC, SEP
You have the right to receive a Good Faith Estimate explaining the expected cost of your care.
Under the No Surprises Act, clients who are uninsured or who are not using insurance to pay for psychotherapy are entitled to an estimate of the expected charges for services. This document provides information about your anticipated costs so that you can make informed decisions about your care.
Please review the information below, including the estimated cost of services and your rights under the No Surprises Act.
Be HERE NOW MINDFULNESS, LLC
GOOD FAITH ESTIMATE
Under the No Surprises Act, individuals who do not have health insurance or who choose not to use their health insurance to pay for care generally have the right to receive a Good Faith Estimate of the expected charges for scheduled health care services.
This Good Faith Estimate provides information about the expected cost of psychotherapy services provided by Be Here Now Mindfulness, LLC.
PROVIDER INFORMATION
Provider: Jennifer Finch, M.A., LPC, ACS, NCC, SEP
Practice: Be Here Now Mindfulness, LLC
Georgia License: LPC004375
Phone: (678) 428-2730
Service Location: In-person and telehealth psychotherapy in Georgia
EXPECTED SERVICES AND CHARGES
Individual Psychotherapy — 60 minutes
Fee: $250 per session
The frequency and duration of psychotherapy vary according to each client’s individual needs. Most clients attend psychotherapy weekly, although sessions may occur more or less frequently depending upon your needs and what we agree upon together.
Because it is not possible to determine in advance exactly how many psychotherapy sessions will be appropriate, your total cost will depend upon the number of sessions you attend.
At the current fee of $250 per 60-minute session, estimated charges would be:
4 sessions: $1,000
12 sessions: $3,000
26 sessions: $6,500
52 sessions: $13,000
These amounts are provided to help you understand the potential cost of ongoing psychotherapy. They are not a recommendation that you attend a particular number of sessions or a prediction of how long you will be in therapy.
The frequency and duration of treatment will be determined collaboratively based upon your needs, goals, and preferences. You may discontinue psychotherapy at any time.
IMPORTANT INFORMATION ABOUT THIS ESTIMATE
This Good Faith Estimate reflects the information known at the time the estimate is provided.
Additional services that are not anticipated or included in this estimate may result in additional charges. If additional services are recommended, we can discuss the expected cost before those services are provided whenever reasonably possible.
This Good Faith Estimate is not a contract and does not require you to receive any services from Be Here Now Mindfulness, LLC.
YOUR RIGHT TO DISPUTE CHARGES
If you receive a bill from a provider or facility that is at least $400 more than the Good Faith Estimate provided by that provider or facility, you may be eligible to use the federal patient-provider dispute resolution process.
Using the dispute resolution process will not adversely affect the quality of health care services you receive.
For more information about Good Faith Estimates and your rights under the No Surprises Act, visit CMS Medical Bill Rights or call 1-800-985-3059.
Please keep a copy of this Good Faith Estimate for your records.