Good Faith Estimate
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.
Providers must inform all self-pay and uninsured patients that a good faith estimate of charges is available.
A good faith estimate of expected charges must be given to the patient within specified time frames (e.g., for services scheduled at least 3 days prior to the appointment date, no later than 1 business day after the date of scheduling).
The estimate is not binding. However, patients may challenge a bill if the charges substantially exceed the estimated amount (any amount over $400).
If there are changes to the information in the good faith estimate, a new estimate should be provided.
The estimate can include anticipated charges for recurring services that are expected to be provided within the next 12 months (e.g., 10-20 psychotherapy sessions). If treatment continues beyond 12 months, the provider must give the patient a new estimate. Please note this is NOT a treatment recommendation, rather just a form created to ensure patients do not receive surprise bills they did not expect.
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 care 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 care provider, and any other provider you choose, for a Good Faith Estimate before you schedule an item or service.
If you receive a session bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill.
Make sure to 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.
Abundant Mercy Christian Counseling LLC (AMCC), Fee Schedule
The following is a detailed list of expected charges. The estimated costs are valid for 12 months from the date of the Good Faith Estimate.
Provider Estimates - *Maximum does not include late cancellation/no show fees, crisis sessions, non-therapeutic charges e.g., documentation fees, banking fees, court/litigation fees, or other financial arrangements based on a case-by-case basis. See 'Practice Policies, Disclosure, and Financial Responsibility' for complete details regarding this fee schedule.
Psychotherapy with clinician:
90791 ~ Intake Session - Individual 50 minutes - $100.00
90791 ~ Intake Session - Couples/Families 50 minutes - $125.00
90834 ~ Individual Psychotherapy, 50 minutes - $100.00
90847 ~ Couples Psychotherapy 50 minutes - $125.00
90847 ~ Family Psychotherapy 50 minutes - $125.00
90791 (99354) ~ Intake Session - Individual 90 minutes - $150.00
90791 (99354) ~ Intake Session - Couples/Families 90 minutes - $175.00
90837 (99354) ~ Individual Psychotherapy, 90 minutes - $150.00
90847 (99354) ~ Couples Psychotherapy 90 minutes - $175.00
90847 (99354) ~ Family Psychotherapy 90 minutes - $200.00
Court/Litigation:
Retainer for court services due IN ADVANCE - $1500.00
Expert Testimony
First hour away from practice: $300
Each additional hour: $250
Each hour of client chart preparation: $250
Communications (phone, text/SMS, email, written letters, etc.) - $250.00 per hour
Travel & Mileage - $250.00 per hour plus $0.56 per mile
Court filing - $100.00 plus associated fees
Therapist legal consultation fees Actual cost
Express service (Less than 72 business hours) -additional $250.00
In-Office Deposition
First hour: $250
Each additional hour: $175
Each hour of client chart preparation: $250
Therapist legal fees: Actual cost
Express service (Less than 72 business hours) -additional $250.00
Summary of Clinical services delivered for 3rd party reimbursement, (i.e.insurance, non-custodial parent) $250.00 per hour
Summary Letter for Court Purposes:
Letter (preparation time included) $250 per hour
including (counseling session dates with start and stop times, the modalities and frequencies of treatment furnished, possible summaries of the following:
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diagnosis
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functional status
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treatment plan, symptoms
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prognosis and progress to date
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personal observations by the clinician of the client, if deemed necessary by counselor)
Express service (Less than 72 business hours) – additional $250.00
Non-Therapeutic/Other Fees: Charge Backs, Non-sufficient funds (NSF), and Documentation Fee - $30.00, Abundant Mercy Christian Counseling.
Length of Services
Psychotherapy services can range from two days to two months, to a year or more. The length of time you will need to be in therapy is based on your therapeutic goals, your overall wants and needs, and any psychosocial/financial barriers that may arise. With this being said, communication is key to any healthy relationship. Should a financial hardship occur, you are encouraged to discuss your situation with Francisco Peralta at AMCC to determine the best resolution as it pertains to your continuity of care and the therapeutic relationship.
Should more time be required to meet your therapeutic goals, we will discuss your options with you at which time a new Good Faith Estimate will be created, your therapeutic services will end, or you are referred to another provider.
The above listed total estimated psychotherapy cost is based on a 52-week structure at the individual rate per one session a week and intake fee of equating to the total. PLEASE NOTE THAT YOUR MAXIMUM CAN AND LIKELY WILL BE LOWER BECAUSE IT CAN BE DIFFICULT TO ACTUALLY HAVE 52 WEEKS OF SERVICES. Your treatment plan might reduce to biweekly or monthly services, and thus be less. These totals above DO NOT account for no show/late cancellation fees, bank charges, crisis sessions, non-therapeutic charges e.g., documentation fees, banking fees, court/litigation fees, or other financial arrangements based on a case-by-case basis. You are encouraged to carefully read the 'Practice Policies, Disclosure, and Fee Agreement' that was in your intake packet for complete details regarding fee schedule.
Disclaimer
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 HHS at (800) 368-1019.
For questions or more information about your right to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprises or call (800) 368-1019.
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.
Provider Estimate
Please review the 'Practice Policies, Disclosure, and Financial Responsibility' for the complete details regarding AMCC fee schedule. *Maximum DOES NOT account for no show/late cancellation fees, bank charges, crisis sessions, non-therapeutic charges e.g., documentation fees, banking fees, court/litigation fees, or other financial arrangements based on a case-by-case basis.
Provider Name: Abundant Mercy Christian Counseling, LLC
Physical Address: 2911 AW Grimes Blvd., Ste. 710
Pflugerville, TX 78660
Therapist: Francisco A Peralta, LPC-S #9899
Phone: 512-413-3638
Email: faperaltacc@gmail.com
Taxpayer Identification Number (EIN): #87-3496169
Details of Services offered at Abundant Mercy Christian Counseling, LLC (AMCC)
Service/Item: Counseling Services
Address where service/item will be provided: Office or Telehealth
Diagnosis code: V65.40 (Z71.9) Other Counseling or Consultation Service code(s):
90791 Psychiatric Diagnostic Evaluation 50-60 minutes (Intake Session) - $100.00
90834 Individual Psychotherapy 60 minutes - $100.00
90846 Family Psychotherapy, conjoint psychotherapy w/o patient present 60 minutes -$125.00
90847 Family Psychotherapy, conjoint psychotherapy w/ patient present 60 minutes -$150.00
90847 Couples Therapy 60 minutes -$125.00
90847 Couples Therapy 90 minutes -$175.00
Quantity (MONTHLY):
1 session @$100.00 = $100.00
12 – 60 minutes sessions (1 session x 1 month x 12 months) @ $100.00 = $1200.00
Quantity (BIWEEKLY):
1 session @$100.00 = $100.00
24 – 60 minutes sessions (1 session x 2-month x 12 months) @ $100.00 = $2400.00
Quantity (WEEKLY):
1 session @$100.00 = $100.00
52 – 60 minutes sessions (1 session x 52 weeks) @ $100.00 = $5200.00
**THIS ESTIMATE DOES NOT TAKE IN ACCOUNT FOR SLIDING FEE BENEFITS AS THOSE BENEFITS ARE BASED ON CLIENTS’ INCOME AND FALL UNDER "OTHER FINANCIAL ARRANGEMENTS". ESTIMATE IS BASED ON FEES QUOTED AT TIME OF INITIAL CONTACT AND CONFIRMED IN CONSULTATION APPOINTMENT.
I acknowledge that I have received the four-page document and understand my right to request a Good Faith Estimate of services to be received.
Signature __________________________________________ Date: _________________
Client Name: ______________________________________ DOB: ___________________
Address: __________________________________________________________________
Phone number: _____________________ Email: __________________________________