Good Faith Estimate (GFE) and Fee Disclosure

GFE valid for 12 consecutive calendar months from todays date.

Details of the Estimate

Primary Services (in bold) and Other Potential Services Frequently Provided and Associated Fees:

Psychiatric Diagnostic Evaluation
CPT Code: 90791GT
Fee: Prorated at $300/60 minutes

Individual Psychotherapy (60 minutes)
CPT Code: 90837GT
Fee: $300

Individual Psychotherapy (45 minutes)
CPT Code: 90834GT
Fee: $225

Individual Psychotherapy (30 minutes)
CPT Code: 90832GT
Fee: $150

Individual Psychotherapy (15 minutes)
CPT Code: 90832GT
Fee: $75

Other Services and Fees: *Due to the unpredictable nature of each client’s circumstances, the following services and fees will not be included in the GFE calculation. This information serves as notice of additional fees you may incur based on your personal circumstances.*

Unscheduled/Ad-Hoc/Crisis/Parent or Guardian Consultation Phone Calls
Prorated at $300/60 minutes

Requested Documentation to Include Treatment Summary, Other Provider Consultation, Other Written Letters, Review of Documents
Prorated at $300/60 minutes

No Call No Show to Scheduled appointment (as defined in the Service Agreement)
$300 or fee for scheduled appointment

Cancelled appointment <24 hours notice (as defined in the Service Agreement)
$300 or fee for scheduled appointment


Frequency and Duration of Treatment
Depending on your treatment needs, services will typically be provided weekly and later reduced to bi-weekly appointments, depending on treatment progress. Monthly, or as-needed maintenance appointments, are reserved for clients who have met treatment goals. Clients with more severe symptoms may meet with their therapist more than once a week. The frequency and duration of treatment is determined between the therapist and client, based on the evaluation, treatment needs, client preferences and treatment progress.

Diagnosis

Z65.9 Problem related to unspecified psychosocial circumstances

The diagnostic code provided here is generic and used to satisfy the requirements of the No Surprises Act and a more specific diagnosis(es) will be provided after the initial evaluation.

Personal Cost Estimation
Your current fee per 60 minute session is $300. Sessions are typically offered on a weekly basis. If the client is engaged and compliant with treatment recommendations, a course of therapy typically ranges from 12-24 sessions, based on industry standards and our clinic average. However, therapy is an extremely personal experience tailored to the needs of the client and presenting concerns. Determining the number of total sessions of treatment is unknown and ethically impossible at the outset, as it is based on a comprehensive evaluation, patient needs and preferences, and progress made in treatment. You and your therapist will continue to review progress and make personalized decisions regarding both the frequency and duration of treatment throughout the course of treatment. Per the Service Agreement, you can decide at any time to terminate services.

Disclaimer
The Good Faith Estimate shows the costs of items and services that are reasonable 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.
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 the health care provider or facility listed to let them know the billed charges are higher than the Good Faith Estimate. You can ask them 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 1-800-985-3059. For questions or more information about your right to a Good Faith Estimate or dispute the process, visit www.cms.gov/nosurprises or call 1-800-985-3059.

Keep a copy of this Good Faith Estimate in a safe place or take a picture of it. You may need it if you are billed a higher amount.

*In an effort to reduce paper waste, this form will be sent electronically for you to sigh and a copy will be kept in your patient portal and in your records.

At Antler Clinic, we do not accept insurance, as it limits our ability to provide the highest level of care. As a small, disabled, LGBTQIA+, woman-owned clinic, we prioritize offering personalized, patient-centered support. To help minimize costs, we provide superbills for patients when possible to submit to their insurance for potential out-of-network reimbursement, ensuring you still have options to maximize your benefits. Below is a list of our fees.


Our services are billed at $300/hr. Services are also prorated in 15-minute increments, rounding to the nearest 15 minute increment.

For more information on how we bill please see our Good Faith Estimate below!