This is an example of a "Good Faith Estimate" that you can receive a copy of when initiating treatment. This is for individuals who are private pay, do not have insurance, or are not utilizing their insurance benefits for therapy.
Jennifer Tzoumas, Ph.D.
Licensed Psychologist
Creative Solutions Behavioral Health PLLC
EIN # 83-3931800
NPI # 1174616239
You have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost.
— Under the new federal law, as of 1/1/2022, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services.
— You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees.
— 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, visit www.cms.gov/nosurprises or call (800) 368-1019.
Expected Services
-All clients receiving psychotherapy will have an initial diagnostic interview (90791), and ongoing standard therapy sessions (90837-50 minute sessions).
After your initial diagnostic interview, we can discuss the applicability of sessions that are 45 minutes or 30 minutes in length and whether that is right for your needs.
Your diagnosis will be discussed at the beginning of treatment and at any point in treatment when it may change or if you have questions about it.
Expected Services:
- 90791 Diagnostic Interview . . . . $175
- 90837 Individual Psychotherapy (50-55 min) minutes) . . . $150
- 90834 Individual Psychotherapy (35-45 min) . . . . $130
- 90832 Individual Psychotherapy (25-30 min) . . . . $85
- Pre-Surgical Evaluation . . . . $350
— I expect that my care of you will require continued individual therapy sessions every 1-2 weeks continuing through the end of the year, at $150 per session. Accounting for expected vacations and holidays, if you are seen every week for a year for a total of 50 weeks, the estimated total is $7500. If you meet every 2 weeks, it would be approximately 25 sessions, for an estimated total of $3750.
— Depending on the progress we make this year, and unknown stressors or life events that may occur, you may need more or less than this estimate can predict. I am happy to discuss this with you at any time.
— You have the right to discontinue treatment with me at any time for any reason (although I would hope we could discuss any issues you may have during treatment so a collaborative solution might be discussed).
— This Good Faith Estimate is not a contract and does not require you to obtain the items or services from any of the providers or facilities identified above in the good faith estimate. You may be able to receive comparable services for reduced price if you see an in-network provider with your health insurance.
— This Good Faith Estimate is valid for the remainder of the calendar year in which it is signed.