Effective January 1, 2022, a ruling went into effect called the “No Surprises Act,” which requires mental
health practitioners to provide a “Good Faith Estimate” (GFE) about out-of-network care to any patient
who is uninsured or who is insured but does not plan to use their insurance benefits to pay for health care
items and/ or services.
The Good Faith Estimate works to show the cost of items and services that are reasonable expected for
your mental 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 are entitled to receive this “Good Faith Estimate” of what the charges could be for psychotherapy services provided to you. While it is not possible for a psychotherapist to know, in advance, how many psychotherapy sessions may be necessary or appropriate for a given person upon the initiation of psychotherapy, this form provides an estimate of the cost of services provided. Your total cost of services will depend upon the number of psychotherapy sessions you attend, your individual circumstances, and the type and amount of services that are provided to you. This estimate is not a contract and does not obligate you to obtain any services from the provider(s) listed, nor does it include any services rendered to you that are not identified here.
IMPORTANT: A formal diagnosis may occur after a diagnostic assessment has been completed.
Your therapist will discuss, as relevant, diagnosis(es) as applicable to treatment.
Calvary Counseling Center, Inc. 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 or group sessions. The number of visits that are appropriate in your case, and the estimated cost for those services, depends on your needs and what you agree to in consultation with your therapist. You are entitled to disagree with any recommendations made to you concerning your treatment and you may discontinue treatment at any time.
- The one-time fee for a Substance Abuse initial diagnostic assessment is $ 280 for VASAP and $20 for initial drug screening.
- The one time fee for Non VASAP initial diagnostic Substance Abuse evaluation is $380 and $20 for initial drug screening.
- Beyond this, the fee for subsequent group sessions (in-person or via telehealth), depending on the time parameters set forth below is between $50.
- All monthly drug screenings are $100 per month.
- Most clients will attend weekly psychotherapy or group sessions 1-2 time per week and is based on treatment plan, and ASAM level of care that has been assessed as well is dependent on individual needs and preference. It is also important, when determining your total estimate, to take into consideration vacations, holidays, emergencies, and sick time.
Subsequent Brief Solution Focus Sessions; will not exceeding $150.00 per session.
You may project any potential future cost(s) by multiplying the sessions by the total number of sessions to calculate your total. This will result in your total estimated cost for service(s).
If you attend treatment for a longer period, your total estimated charges will increase according to the number of visits and length of treatment.
You and your counselor will continually assess the appropriate frequency of treatment 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 the frequency of session(s) or needs change. As related, you may request a new GFE at any time in writing during your treatment.
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. Your provider may recommend additional services that are not reflected in this Good Faith Estimate.
The Good Faith Estimate is only an estimate—actual items/ service charges may differ. The Good Faith
Estimate does not include any unknown or unanticipated costs that may arise and are not reasonably.
expected during treatment due to unforeseen events. You could be charged more if complications or
special circumstances occur. Other potential items and/ or services associated with therapy charges may
include but is not limited to no show/ late cancellation fee(s), record request(s), letter writing(s), legal fee(s)/ court attendance(s), professional collaboration(s), and in-between session supports). These potential items services and associated fee(s) are discussed further within the Informed Consent documentation and should these items/services be initiated a new Good Faith Estimate will be provided. The Good Faith Estimate does not obligate the client to obtain listed items or services. You have a right to initiate a dispute resolution process if the actual amount charged to you substantially exceeds the estimated charges stated in your Good Faith Estimate. You are encouraged to speak with your provider at any time about any questions you may have regarding your treatment plan, or the information provided to you in this Good Faith Estimate.
For questions or more information related to the Good Faith Estimate, visit
www.cms.go/nosurprises or
call (800) 368-1019. Keep a copy of this Good Faith Estimate in a safe place. With my signature for this Good Faith Estimate, I acknowledge that I am not obligated or required to obtain any of the listed services from this provider and that I am consenting of my own free will, free from coercion or pressure. I also understand that:
- I am giving up some consumer billing protections under federal law.
- I agree to “fee for service” and will pay out-of-pocket.
- I was given notice explaining that my provider and/or practice is not in my health plan’s network AND DOSE NOT ACCEPT INSURANCE. the estimated costs of services, and what I may owe if I agree to be treated by this provider and/ or practice.
- I have received notice both verbally and written/ electronically.
- I can end this agreement by notifying the provider and/ practice in writing before receiving items
and/ or services.
IMPORTANT: You are not required to sign this form; however, if you do not sign, the provider and/ or
practice may not treat you. You have the right to choose to get care from a provider and/or practice that is within your health plan’s network.
