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Good Faith Estimate

The No Surprises Act, as the name indicates, was designed for situations in which you might be surprised by a large medical bill for services for which you did not know the cost in advance. It’s the kind of situation that arises especially in hospitals, when you may be receiving treatment from many providers, sometimes without consulting you first. In the context of your work with Dr. Chalmer, this situation cannot occur, because you always know the cost of his services beforehand, and can choose to use them or not. However, the law requires that even sole practitioners provide this document. The law requires this document only for self-pay services. If you are using insurance for your sessions with Dr. Chalmer, this document does not apply to you.

The estimates below are the ranges of costs for services from Dr. Chalmer through the above date. Please be aware that your actual cost will depend entirely on how many sessions you choose to have, which Dr. Chalmer cannot predict.

For 45-minute sessions, the “expected cost” estimate assumes 10 to 40 sessions over the course of a year. Very few of Dr. Chalmer’s patients do 40 or more sessions in a year, so the upper portion of this range is very unusual, but is possible if you choose to have that many sessions.

For Couple Intensives, the “expected cost” estimate assumes 5 to 30 sessions averaging 90 minutes each over the course of a year. Again, the upper portion of that range is very unusual in Dr. Chalmer’s practice, but possible if you choose to have that many sessions.

For the total estimated cost, the estimate assumes a mix of 5 to 20 Couple Intensives and 5 to 20 45-minute sessions. Again, your actual cost will depend entirely on the actual services you use, for which you know the cost up front. If you choose fewer or shorter sessions, your cost will be less than the lower end of the range. It’s unlikely, but theoretically possible, that you could schedule enough sessions with Dr. Chalmer to exceed to top of the range.

If you have questions about this estimate, please contact Dr. Chalmer.

Details of the Estimate

Service Diagnosis Code Service code Quantity (# of sessions)   Cost per session Expected cost
Initial evaluation F43.20 90791 1 $180 $180
Psychotherapy – 45 minutes F43.20 90834 9 – 39 $150 $1350 – 6000
Couple intensive Not assigned None 5 – 30 $250 – 450 $1500 – 9000

Total estimated cost: $2430 – $9030

Disclaimer

This Good Faith Estimate shows the costs of services that are reasonably expected for services to address the needs for which you are consulting Dr. Chalmer. The estimate is based on the information known to Dr. Chalmer when he 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 more than this Good Faith Estimate, you have the right to dispute the bill.

You may contact Dr. Chalmer at the contact listed above to let him know the billed charges are higher than the Good Faith Estimate. You can ask him 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 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 Good Faith Estimate is not a contract. It does not obligate you to accept the services listed above.

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