Good Faith Estimate
Forge Therapy, PLLC
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.
You have the right to receive a Good Faith Estimate in writing before your first appointment, or at any time upon request. This estimate is provided to help you understand and plan for potential out-of-pocket costs.
Who This Applies To
This notice applies to:
- Clients who are uninsured
- Clients who are paying out of pocket (self-pay) for any reason, including choosing not to bill insurance
If you are using insurance, your costs will depend on your specific plan, deductible, copay, and coverage. Please contact your insurance provider for an estimate of your out-of-pocket costs.
What a Good Faith Estimate Includes
Your Good Faith Estimate will include:
- Expected costs for services provided by Forge Therapy, PLLC
- A description of the services to be provided
- Diagnosis and service codes when applicable
- The name and contact information of the provider
The estimate reflects expected costs for a typical course of services. Actual costs may vary depending on your individual needs, the length of treatment, and any changes to the services provided.
Current Session Rates
Individual therapy sessions (50 minutes): $150 Initial intake/assessment session: $190
Therapy is an individualized process. The number of sessions needed varies by person. We are happy to discuss your treatment goals and a general timeframe during your consultation.
If Your Bill Is Higher Than Your Estimate
If you receive a bill that is at least $400 more than your Good Faith Estimate, you have the right to dispute the bill.
To start the dispute process:
- Contact the provider whose bill you are disputing
- Visit www.cms.gov/nosurprises for information on the dispute process
- Save a copy of your Good Faith Estimate
For questions or to request a written Good Faith Estimate before scheduling, contact us at:
Forge Therapy, PLLC andi@forgetherapy.org 405-254-6206