Good Faith Estimate Disclaimer
Under federal law, health care providers must give clients who don’t have insurance, or who are not using insurance, an estimate of expected charges for medical services, including psychotherapy services.
This Good Faith Estimate outlines the anticipated costs of psychotherapy services reasonably expected for your mental health care needs. The estimate is based on information available at the time of creation and may not include unforeseen or unexpected costs that arise during treatment. You may be charged more if complications or special circumstances occur. If this happens, federal law allows you to dispute (appeal) the bill.
While it is not always possible to predict the exact number of sessions that will be needed, this estimate offers a general cost projection based on your current treatment plan. The total cost of services depends on how many sessions you attend, your individual circumstances, and the nature of the services provided. This estimate does not constitute a binding contract and does not obligate you to receive services. It also does not include fees for missed appointments or late cancellations, which are outlined in the Practice Policies.
You have the right to discuss and decline any recommendations made in your treatment, and you may discontinue services at any time.
If you are billed for more than the Good Faith Estimate, you have the right to dispute the bill.
You may contact Foye-Fletcher Therapy LLC to review or request adjustments to a bill that exceeds your Good Faith Estimate. You may also negotiate the bill or inquire about financial assistance.
Additionally, you may initiate a dispute resolution process with the U.S. Department of Health and Human Services (HHS) within 120 calendar days (approximately 4 months) from the date of the original bill. A $25 fee applies to initiate the process. If the agency finds in your favor, you’ll only be responsible for the amount listed in the Good Faith Estimate. If the agency sides with the provider, you may be required to pay the higher amount.
Learn more or access dispute forms at www.cms.gov/nosurprises or by calling (800) 368-1019.
It is recommended that you keep a copy of your Good Faith Estimate for your records.
Acknowledgment
I understand that I will receive a Good Faith Estimate after Angelique Foye-Fletcher, LMFT, LCMFT, RPT receives and reviews my intake paperwork.
I understand that the Good Faith Estimate is an estimate, and does not represent a payment due in full for services up front.
Payment Card on File Requirement
All clients are required to have a valid card on file. Payment is collected at the beginning of each session. If your card needs to be updated, please inform Foye-Fletcher Therapy LLC prior to your scheduled session.
Cancellation and No Show Policy
Please refer to the Practice Policies for details on late cancellation and no-show fees. These fees are subject to change; however, you will be notified in advance of any updates.
Returned Check Policy
A $10.00 service fee will be charged for any returned checks due to insufficient funds or other processing issues.