Privacy policy.
Your privacy is important. Please follow the link above, “Your rights under HIPPA,” to get specifics on how your information is protected.
All electronics used by ACE Counseling Services, LLC comply with HIPPA standards, to include email, text, phone, video calls, electronic health records (EHR), and computer.
Good Faith Estimate Example
Ace Counseling Services, LLC., does not take insurance. Therefore, we are required to provide a GFE to private paying clients. The following is an example of the GFE you will receive during your first session.
ACE Counseling Services, LLC.
5411 Plaza Dr., Suite D
Texarkana, TX 75503
903-518-8498
Good Faith Estimate
Date of Good Faith Estimate: ___/____/___ This estimate is for psychotherapy services through [Date].
The estimate below is the range of costs/cost that is likely for most new clients. Until I do an initial evaluation and we start to work together, I will not have a clear picture of your specific diagnosis, issues, and needs. I typically see therapy clients for 26-50 sessions (6 months-year) for a total cost of $2600.00 - $4900. But in many cases a client’s issues may be more complicated, so we may need additional sessions during the time covered by this estimate. The estimate below is the range of cost that I think is likely for your care over the time period covered by this estimate. However, depending on how treatment progresses, more or fewer sessions may be needed.
If you have questions about this estimate, please contact Elizabeth Penick, LPC, NCC, CCTP at 903-518-8498.
Details of the Estimate
The following is a detailed list of expected charges for psychological services scheduled for [date or dates]. The estimated costs are valid for 12 months from the date of this Good Faith Estimate, unless I send you an updated Estimate.
Service Diagnosis Code (once determined)
Service code Quantity (# of sessions or units. Give number or range)
Cost per unit: $100.00-$125.00
Expected cost: $
Psychotherapy 90837 ($125.00) and/or 90834 ($100.00)
Total estimated cost: $____[number or range]____________
Provider: Elizabeth Penick, LPC, NCC, CCTP
NPI number: 1689194003 EIN: 88-4377761
Client information:
Client name : _________________________________ DOB ______________
Disclaimer
This Good Faith Estimate shows the costs of services that are reasonably expected for the expected services to address your mental health care needs. The estimate is based on the information known to me when I did the estimate.
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 $400 more (per provider) than this Good Faith Estimate (GFE), you have the right to dispute the bill. You may contact ACE Counseling Services, LLC. at the contact listed above to let them know the billed charges are at least $400 higher than the GFE. You can ask them to update the bill to match the GFE, 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 GFE. If the agency disagrees with you and agrees with the health care provider or facility, you will have to pay the higher amount.
To learn more and get a form to start the process, go to: www.cms.gov/nosurprises or call CMS at 1-800-985-3059. For questions or more information about your right to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprises or call CMS at 1-800-985-3059.
This GFE is not a contract. It does not obligate you to accept the services listed above.
Keep a copy of this Good Faith Estimate (GFE) in a safe place or take pictures of it. You may need it if
you are billed more than $400 than the estimate provided above.
I have received a copy of this GFE:
________________________________________________Date:____________