Under Section 2799B-6 of the Public Health Service Act, health care providers and health care facilities are required to provide a good faith estimate of expected charges for items and services to 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, upon request or at the time of scheduling health care items and services. This form may be used by the health care providers to inform individuals who are not enrolled in a plan or coverage or a Federal health care program (uninsured individuals), or individuals who are enrolled but not seeking to file a claim with their plan or coverage (self-pay individuals) of the expected charges they may be billed for receiving certain health care items and services. A good faith estimate must be provided within 3 business days upon request. Information regarding scheduled items and services must be furnished within 1 business day of scheduling an item or service to be provided in 3 business days; and within 3 business days of scheduling an item or service to be provided in at least 10 business days.
Under current law, health care providers need to give patients who do not have insurance, or who do not plan to use their insurance, or who may be planning to submit for out of network benefits, an estimate of the bill for medical items and services.
This Good Faith Estimate shows the costs of items and services that are reasonably expected for your mental health care. It is based on information that is 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.
You may contact Jung Psych Services to inform them that the billed charges are higher than the Good Faith Estimate. You can request to update the billl 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 US Department of Health and Human Services (HHS). If you chooose 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 be required to pay the price on this Good Faith Estimate. If the agency disagrees with you, and agrees with Jung Psych Services, you will have to pay the higher amount.
To learn more and get a form to start the dispute process, go to www.cms.gov, or call 1-800-985-3059.
These rates are subject to change.
|60 min Therapy(90837)||$200.00|
|45 min Therapy(90834)||$150.00|
|30 min Therapy(90832)||$100.00|
|Phone Consult, 15 min (98966)||$50.00|
|Documentation (FMLA/STD paperwork)||$200.00 (prorated)|
|Failure To Cancel Appointments Within 24 Hours||$50.00|