Good Faith Estimate

Good Faith Estimate for Services 

The following information will be made available on client’s first and all subsequent Super Bills: Provider Name: Taylor Williams, LCSW 

Provider Address: 3104 E. Camelback Rd. #7287; Phoenix, AZ 85016 

Provider Phone: 480-482-0629 

Provider Tax ID: 87-2853639 

Provider License: Arizona-LCSW-19664; California-LCSW-100104 

Provider NPI: 1295212892 

Client Name 

Client Address 

Client Date of Birth 

Primary Diagnostic Code 

Service Code and Name of Service 

Date of Session 

***Please Note: If another entity or person is paying for your psychotherapy services, you are receiving this estimate so that you may be adequately informed of the fees that will be billed to them and paid by them. 

***Please Note: There is no guarantee that your insurance company will provide reimbursement for therapy services using a Super Bill, as everyone’s insurance plan is different. If you have not already done so, be sure to contact your insurance company to understand what, if any, reimbursement benefits you may or may not be entitled to. That way, there are no surprises for you once you’ve started treatment. Additionally - because there is no way to refund a service that was already provided, our practice does not provide refunds for any reason at any time. 

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, this form provides an estimate of the cost of services provided. Your therapist’s clients typically require 6-12 sessions per target, though this range represents an estimate and is subject to fluctuate depending on each client’s circumstances and needs. 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 Good Faith Estimate shows the costs of services that are reasonably expected for your behavioral health care needs.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. 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. There may be additional services that your psychotherapist may recommend as part of your care that must be scheduled or requested separately and that are not reflected in this Good Faith Estimate. Any additional services will be discussed with you prior by your psychotherapist to avoid any surprise charges.

You have the 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 (which means $400 or more beyond the estimated charges). You may contact your psychotherapist or the practice listed to let them know the billed charges are higher than the Good Faith Estimate. You can ask them to update the bill to match the Good Faith Estimate, 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 Good Faith Estimate. If the agency disagrees with you and agrees with your psychotherapist or the practice, you will have to pay the higher amount. 

For questions or more information about your right to a Good Faith Estimate or the dispute resolution process, visit https://www.cms.gov/nosurprises/consumers or call 1- 800-985-3059. The initiation of the client-provider dispute resolution process will not adversely affect the quality of the services furnished to you. 

Until psychotherapy services get underway, it can be difficult for a psychotherapist to accurately estimate the total cost of treatment for you. However, treatment range examples can be used to help client and psychotherapist begin to estimate the cost of services. Using a 3-month treatment range as an example: 

If a client attends weekly 60-minute psychotherapy sessions throughout the next 3 months at $185 per session for a total of 12 weeks (using the 3-month example) taking into consideration availability (e.g., vacations, holidays, emergencies, sick time, etc.) for an estimated total of $185 x 12 weeks = $2,220. Based upon a fee of $185 per visit, if you attend 1 psychotherapy session per week, your estimated charge would be $740 for 4 visits provided over the course of 1 month; $1,480 for 8 visits over 2 months; or $2,220 for 12 visits over 3 months. If you attend psychotherapy for a longer period, your total estimated charges will increase according to the number of session and length of treatment. 

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 visits (i.e., 3 months is not a standard amount of psychotherapy treatment per se, this was just used an example of how to calculate cost of services). 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 psychotherapist. You are entitled to disagree with any recommendations made to you concerning your treatment and you may discontinue treatment at any time. 

You are encouraged to speak with your psychotherapist at any time about any questions you may have regarding your treatment plan, or the information provided to you in this Good Faith Estimate. 

BY PROVIDING MY ELECTRONIC SIGNATURE I AM AGREEING THAT I HAVE READ, UNDERSTOOD AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT.