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Good Faith Estimates

Good Faith Estimates of Cost of Services for Self-Pay Clients

You are entitled to receive a Good Faith Estimate of what the charges could be for therapy services provided to you. While it is not possible for a therapist to know in advance how many therapy sessions may be necessary or appropriate for a given person, this form provides an estimate of the cost of services provided. Your total cost of services will depend upon the number of therapy sessions you attend, your individual circumstances, and the type and amount of services that are provided to you.  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 not a contract and does not obligate you to obtain any services from the provider listed, nor does it include any services rendered to you that are not identified here.  The estimate and potential diagnosis 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 items or services recommended as part of your care that must be scheduled or requested separately and are not reflected in this Good Faith Estimate. You could be charged more if complications or special circumstances occur. If this happens, federal law allows you to dispute (appeal) the bill.  

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 ($400 or more beyond estimated charges). You may contact Living Stones Counseling Services (LSCS) to let them know the billed charges are higher than the Good Faith Estimate. You can ask LCSC 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 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.  For questions or more information about your right to a Good Faith Estimate or the  dispute resolution process, visit or  call 1- 800-985-3059. The initiation of the patient-provider dispute resolution process will not adversely affect the quality of the services furnished to you.  

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. 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 therapist. You are entitled to informed consent and make the final decisions concerning your treatment, including frequency of sessions and discontinuation of services. You are encouraged to speak with your provider at any time about any questions you may have regarding your treatment plan, or the information provided to you in this Good Faith Estimate.  

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