Good Faith Estimate Disclaimer

Effective January 1, 2022, a ruling went into effect called the "No Surprises Act" which requires practitioners to provider a "Good Faith Estimate" about out-of-network care. The Good Faith Estimate (GFE) works to show the cost of items and services that are reasonably expected for your mental health care needs for an item or service, a diagnosis, and a reason for therapy. Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the expected charges for medical services, including psychotherapy services.

You have the right to receive a “Good Faith Estimate” explaining how much your medical and mental health care will cost. The estimate is based on information known at the time the estimate was created. The GFE does not include any unknown or unsuspected costs that may arise during treatment. You could be charged more if complications or special circumstances occur and will be provided a new "Good Faith Estimate" should this occur.

You’re getting this notice because this provider (Samantha Carlton) or facility isn’t in your health plan’s network and is considered out-of-network. This means the provider or facility doesn’t have an agreement with your plan to provide services. Getting care from this provider or facility might cost you more than utilizing your in-network insurance benefits.

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, click here.

Potentially ongoing services, such as couples psychotherapy, family psychotherapy, and individual psychotherapy are estimated to continue for six months. For the purposes of this GFE, a six-month treatment duration is the default number. The actual duration will vary based on need and availability.

The actual frequency and duration of sessions can be difficult to predict as therapy is seldom static, every situation is different, circumstances change, and people have varying needs. This should be an ongoing and collaborative conversation between you and your provider.

Clients can estimate the cost of services by multiplying the Service Item Cost by the Number of Sessions. Your Good Faith Estimate will be calculated as follows: Service Item Cost x 62 (weeks in a 6-month period) = Y.

A more thorough breakdown of my services fees has always been, and will continue to be, clearly presented in my Informed Consent for Psychotherapy document. This document is included with the client intake paperwork packet. Please contact me for more information.