GOOD FAITH ESTIMATE

Effective January 1, 2022 a ruling went to effect called the “No Surprises Act” which requires practitioners to provide a “Good Faith Estimate” (GFE) about out-of-network care. The GFE is a notification of expected charges for a scheduled or requested service.

Under Section 2799B-6 of the Public Health Service Act, health care providers and health care facilities are required to inform individuals who are not enrolled in a plan or coverage or a Federal health care program, or not seeking to file a claim with their plan or coverage both orally and in writing of their ability, upon request or at the time of scheduling health care items and services, to receive a “Good Faith Estimate” of expected charges.

INITIAL GOOD FAITH ESTIMATE

Name of Patient:

Date of Birth:

Diagnosis: TBD

PROFESSIONAL FEES:

( x ) Initial Consultation/Assessment (60-90 minutes) $400

90791: Diagnostic Evaluation (no med)

90792: Diagnostic Evaluation (w/ med)

99205: Comp/Comp/High (time 60-74 min)

( ) Psychotherapy with/without med management (50-55 minutes) $275

99215: Comp/CompHigh time 40–54 min

90837: PsyTx (53+ min)

( ) Brief psychotherapy/medication follow up (about 25 minutes) $195

99214: Comp/Comp/Mod time 30–39 min

Additional services such as record review, completion of forms, prior authorizations, disability paperwork, scheduled phone consults - billed in 15 minute increments prorated at $390/hr at Dr. Harrison's discretion.

Provider: Ari Harrison, M.D.

NPI: 1386706927

EIN/Federal Tax Id#: 20-2929898

Location: 725 Farmers Ln #8
Santa Rosa, CA 95405

707-575-5815

Telehealth

Disclaimer

There may be additional items or services the convening provider or convening facility recommends as part of the course of care that must be scheduled or requested separately and are not reflected in the good faith estimate;
The information provided in the good faith estimate is only an estimate and that actual items, services, or charges may differ from the good faith estimate; and
The patient has the right to initiate a patient-provider dispute resolution process if the actual billed charges substantially exceed the expected charges included in the good faith estimate. The initiation of a patient-provider dispute resolution process will not adversely affect the quality of health care services furnished to the patient
The good faith estimate is not a contract and does not require the uninsured (or self-pay) individual to obtain the items or services from any of the providers or facilities identified in the good faith estimate.
This 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.
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 the dispute process, visit www.cms.gov/nosurprises or cal 1-800-985-3059.
Keep a copy of this Good Faith Estimate in a safe place or take pictures of it. You may need it if you are billed a higher amount.

Good Faith Estimate: Service