Good Faith Estimate
Under Section 2799B-6 of the Public Health Service Act, health care providers and health care 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 the GFE does not apply currently to any clients who are using insurance benefits, including Out of Network Benefits (seeking reimbursement from your insurance companies). You have the right to receive a “good faith estimate” explaining how much your medical care will cost. Under the law, healthcare providers need to give patients who do not have insurance or who are not using insurance an estimate of the bill for medical items and services.
You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees.
Make sure your health care provider gives you a Good Faith Estimate in writing at least 1 business day before your medical service or item. You can also ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule an item or service.
If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill.
Make sure to save a copy or picture of your Good Faith Estimate.
For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises or call (800) 368-1019.
**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 $400 over 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. 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.
Applicable Fees for Treatment
The following is a detailed list of expected or potential charges. The estimated costs are valid for 12 months from the date of the Good Faith Estimate (date that the document was sent to you). Please note that this is only an estimate.
Any services scheduled separately or in addition to below are not reflected in this good faith estimate (such as costs associated with any sort of treatment related letters, telephone conversations, site visits, writing and reading of reports, consultation with other professionals, release of information, reading records, and longer sessions, etc.) will be charged at the same rate, unless otherwise arranged. Participation in legal proceedings including appearance, preparation, and travel time carries a charge of $350 per hour for preparation and attendance, unless indicated and agreed upon otherwise.
If through our work together, we mutually decide that the addition of couples/individual sessions would be beneficial to you, this is also not included in this estimate and will be charged at the standard session rate agreed to with your therapist.
Note about Estimates Related to Psychotherapy
Because everyone comes to therapy with different concerns and experience things in a way that is unique to them, making an estimate about the costs of psychotherapy is difficult. This also does not take into account that people respond to treatment in different ways or that psychosocial factors can change which has the potential to lengthen the process of therapy. How long and how often we meet may also be impacted by factors such as your schedule, your therapist’s schedule, ongoing life challenges, and personal finances. Some people choose to seek therapy more long term and consider it an important aspect of their lives. Others choose to focus on one issue and then discontinue therapy when that issue has resolved. You are allowed to terminate your therapy at any time. There is the potential throughout the course of treatment that we may find we need to meet with more frequency (for example, moving from biweekly appointments to weekly appointments) and may move back to biweekly appointments once the issue of concern is stabilized. If we switch from biweekly to weekly sessions, the estimate of what services will cost you in a 12 month period will change, reflective of however many weeks are left in the year multiplied by the fee per session. The Good Faith Estimate also does not include any potential costs listed above in the “Applicable Fees for Treatment” paragraph.
We are also especially unable to provide an estimate on the length of treatment or a diagnosis to a client that we have never met.
Company and Provider Information
Practice Name: Clementine Counseling PLLC
Provider: Josephine Bibby, LPC
Phone: (512) 710-5828
Email: josephinebibbycounseling@gmail.com
NPI: 1992446884
EIN: 88-1629173
Common Services at Clementine Counseling PLLC (CPT Codes):
90791-95 Psychiatric Diagnostic Evaluation - Telehealth (for new clients only)
90834-95 Individual Psychotherapy - Telehealth (45 minute sessions)
90847-95 Couples/Family Therapy - Telehealth (45 minute sessions)
Cost Per Session
$150 per psychotherapy session (90791-95, 90834-95,90847-95)
Diagnosis
Therapists are unable to provide a diagnosis prior to seeing a new client. If needed, a diagnosis may be provided to you by your therapist after your initial appointment has concluded. This diagnosis may or may not need to be altered depending on new information that emerges throughout your time in therapy as conditions may be ruled out, or new conditions may be discovered. Please ask your therapist about any questions you may have regarding your diagnosis.
Estimates
Please note that the estimates provided below based on services provided throughout a year are a maximum but that you actually will likely pay much less due to factors like cancellations, holidays, vacations, etc. as well as if you have an alternate fee arranged such as a sliding scale fee.
Weekly Individual/Couple & Family Psychotherapy Sessions at $150 per session (90791-95/90834-95/90847-95 – 52 sessions): $7800
Every Other Week Individual/Couple & Family Psychotherapy Sessions at $150 per session (90791-95/90834-95/90847-95 – 26 sessions): $3900
Monthly Individual/Couple & Family Psychotherapy Sessions at $150 per session (90791-95/90834-95/90847-95 – 12 sessions): $1800
Late Cancellation/No Show Fees
Late cancellation or no show fees are charged when there is less than a 24 hour notice provided for cancellations of a scheduled session or service. Emergency circumstances will be reviewed and determined on a case by case basis with your therapist. The fee for a late cancellation or no-show appointment is your full session fee.
By signing below you are indicating that you have reviewed the information on good faith estimates and have received the estimate for what your mental health services may cost you for a year of services. Again, please note that these are only estimates and you will likely pay less than the estimate.
