In accordance with the new “No Surprises Act,” the following is a detailed list of expected charges for your psychotherapy scheduled for 12 months.
A Good Faith Estimate shows the costs of items and services that are reasonably expected for your health care needs for an item or service. The estimate is based on information known at the time the estimate was created.
Diagnosis
Mountains Therapy LLC must code all clients at the onset of services with a Diagnosis from the Diagnostic and Statistical Manual of Mental Health Disorders: DMS 5 for legal, insurance, and federal requirements.
Diagnosis changes will not impact a change in fees
You and your therapist will continually assess the appropriate frequency of therapy and will work together to determine when you have met your goals and are ready for discharge and/or a new "Good Faith Estimate" will be issued should your frequency or needs change.
There may be additional items or services that your provider recommends as part of the treatment that will be scheduled separately and are not reflected in the good faith estimate.
The information provided in the good faith estimate is only an estimate and actual items, services, or charges may differ from the good faith estimate.
The good faith estimate does not require you to obtain psychotherapy or other services from Mountains Therapy LLC.
For questions or more information about your right to a Good Faith Estimate or the dispute process, visit https://www.cms.gov/nosurprises/consumers or call (800) 368-1019.
This notice will be in effect on the date signed by the client.
Email Address:
Phone Number:
Call 988 Suicide and Crisis Lifeline or visit emergency room, If you are in a mental health crisis or any other person may be in danger,