Good Faith
Estimate

Effective: January 1, 2022  ·  Last reviewed: January 1, 2025

Your Right to a Good Faith Estimate

Under the No Surprises Act (effective January 1, 2022), you have the right to receive a Good Faith Estimate of expected costs for healthcare services, including mental health services, before your first appointment if you are:

• Uninsured (do not have health insurance), or
• Choosing not to use your health insurance for services at this practice

A Good Faith Estimate is not a contract and does not require you to obtain services. It is an estimate of the costs you may expect to pay based on the information available at the time of scheduling.

What Is Included in the Estimate

The Good Faith Estimate includes:

• The expected cost of each service provided
• The diagnostic and service codes associated with those services
• The estimated number of sessions for a course of treatment, to the extent reasonably predictable
• Provider name, credentials, and contact information

Because the course of mental health treatment depends on individual factors that become clearer over time, the estimate reflects the provider’s best professional judgment at the time of scheduling and may change as treatment progresses.

Current Service Rates

The following rates apply to self-pay clients (those not using insurance) at Positive FX Counseling & Wellness, PLLC:

• Initial Intake and Evaluation (90837 / 90791): $200 per session
• Individual Psychotherapy, 60 minutes (90837): $175 per session
• Free Consultation (15 minutes): $0

Payment is due at the time of service and is processed securely through Headway.

Your Protections

If you receive a bill that is at least $400 more than your Good Faith Estimate for a service, you have the right to dispute that bill. To dispute a bill:

• Contact the practice directly at (561) 363-7542 to attempt resolution
• Start the dispute process with the U.S. Centers for Medicare and Medicaid Services (CMS) at cms.gov/nosurprises or call 1-800-985-3059
• You must initiate a dispute within 120 calendar days of the date on the original bill

Requesting Your Good Faith Estimate

To receive a written Good Faith Estimate before your first session, contact the Practice at:

• Phone: (561) 363-7542
• Contact form: positivefxcounseling.com/contact.html

The estimate will be provided to you within 1 business day of scheduling for appointments booked at least 3 business days in advance, and within 3 business days for appointments booked at least 10 business days in advance, as required by law.

Insurance Clients

If you are using insurance, your out-of-pocket costs will depend on your specific plan, deductible, copay, and coinsurance amounts. The Practice cannot guarantee what your insurer will cover. Verifying your benefits before your first session is strongly recommended. Contact your insurer directly or ask June to assist during the free consultation.

Additional Information

For more information about your rights under the No Surprises Act, visit the CMS website at cms.gov/nosurprises.