As of January, 2022, healthcare providers must provide a Good Faith Estimate, which is an estimate for the cost of their services. The purpose of this estimate is to provide you with estimated costs you may incur while working with your therapist at Wellness Studio.

This Good Faith Estimate below shows the costs of reasonably expected services to address your mental healthcare. The estimate is based on weekly, bi-weekly, and monthly sessions.

Quantity                          Weekly sessions at $130 per session
$130x52 sessions        Total expected cost=$6,760   
 
                                           Bi-weekly sessions at $130 per session
$130x26 sessions        Total expected cost=$3,380 
 
                                           Monthly sessions at $130 per session
$130x12 sessions          Total expected cost=$1,560  

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, such as but not limited to changes in session frequency (e.g. going from weekly to bi-weekly, bi-weekly to weekly) late cancellations, no-shows, and add on sessions. Your Good Faith Estimate will be provided to you before your intake session.

If you are billed for $400 more than this Good Faith Estimate, you have the right to dispute the bill.

You may contact the person listed below if billed charges are higher than the Good Faith Estimate. You can request an update to 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 CMS at 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 call CMS at 1-800-985-3059.

This Good Faith Estimate is not a contract. It does not obligate you to accept the services listed above.

Contact person: Kenley Breckenridge