Good Faith Estimate of Costs

In late 2021, Congress passed a law which requires healthcare practitioners to provide a "good faith estimate" of expected costs of your healthcare should you opt out of insurance coverage or should you not have insurance (there are also new laws that help minimize impact of non-network services being offered as a "surprise" as part of a hospital stay - for this reason, the law is called the "No Surprises Act." This page contains everything you need to know about the No Surprises Act and also provides a Good Faith Estimate of my services.

Accountant at Work

Good Faith Estimate Notice

You have the right to receive a "Good Faith Estimate" explaining how much your medical care will cost. 

Under the law, 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.

  • Make sure your health are provider gives you a Good Faith Estimate in writing at least 1 business day before your medical service or item. You can also ask your health car providers, and any other provider you choose, for a Good Faith Estimate before you schedule an item or service.

  • If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill.

  • Make sure you 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 Chattanooga Peds billing office at 423-497-8760.

Sample Good Faith Estimate

This form is the Good Faith Estimate (GFE) I use in my practice. It contains an estimate of expected costs for professional services. A full description of expected costs can be found in my Forms page.

Jason L. Steadman, Psy.D. ABPP

Chattanooga Pediatrics

3328 Jenkins Road, Suite 200

Chattanooga, TN 37421

(423)825-4040

Date of Good Faith Estimate __________________. This estimate is for psychotherapy services for 1 year from the date of this estimate, unless we send you an updated estimate sooner.

The estimate below is based on most likely expected costs based on the clinical information present at the time of the estimate. For new patients, this estimate includes an intake/initial evaluation, after which we will discuss more formally the expected frequency of sessions. For ongoing patients, you can expect to continue the same frequency as usual, unless we discuss otherwise. Psychotherapy services are difficult to predict at times with regard to the duration and frequency of services. This estimate is based on what I usually expect for patients like you, but of course things can change and we may need to see each other more frequently or less frequently than what we estimate in this agreement. Most often, I see patients every 1 to 2 weeks, though sometimes less frequently. At an out-of-pocket cost (without insurance) of $100 per session, this means that you can expect the total annual cost of 1 year of psychotherapy to range between $2600- $5200. Most patients do not receive weekly services for a full year though, and man can complete a course of therapy in 10-15 sessions, which would equate to $1000-$1500 out-of-pocket costs total. 

Details of the estimate

The following is a detailed list of expected charges for psychological services for ___[patient name]____ from _____[anticipated date range]___. The estimated costs are valid for 12 months from the date of this GFE, unless you are given an updated estimate.

  • Initial evaluation (CPT Code 90791) = $160. This is a one time cost for the first appointment only. 

  • 45-60 minute therapy session (90834 or 90837) = $100. This is cost per session. I anticipate having up to _________ sessions, for a total cost of $__________

  • Testing (these fees are covered in more detail elsewhere on my website): Tier I = $500; Tier II = $900; Tier III = $1150. These are flat rate fees that cover an entire testing service.