Good Faith estimate

We are required to provide you with a Good Faith Estimate of the cost of services when requested. It is difficult to determine the true length of treatment for mental health care, and each client has a right to decide how long they would like to participate in mental health care. Therefore, below you will find a fee schedule for the services typically offered by your therapist, and we will collaborate with you on a regular basis to determine how many sessions you may need.

If you would like to receive your own Good Faith Estimate for services, please request this from your treating clinician.

Total cost estimate of what you may be asked to pay:

It is your ethical right to determine your goals for treatment and how long you would like to remain in therapy unless you are pursuing mandatory treatment. Please see the provided breakdown of possible fees.

Review your detailed estimate. See provided page for a cost estimate for each item or service.

Call your health plan. Your plan may have better information about how much of these services are reimbursable.

Questions about this notice and estimate? Call Kristina Smith, (949) 633-0482

Questions about your rights? Contact: Board Of Behavioral Sciences at www.bbs.ca.gov

Prior authorization or other care management limitations:

Except in an emergency, your health plan may require prior authorization (or other limitations) for certain items and services. This means you may need your plan’s approval that it will cover an item or service before you get them. If prior authorization is required, ask your health plan about what information is necessary to get coverage.

GOOD FAITH ESTIMATE TABLE OF SERVICES AND FEES: Fees listed below are the highest fees charged at Village Wellness and are for Licensed Therapists. You may not be charged at the highest rate and are encouraged to speak with your treating clinician about your specific fee.

Service code/ Description / Fee for Service
(CPT Code) (Number of Sessions Will Be Determined as
We Progress)

90791/ Initial Diagnostic Evaluation/ $200.00

90837/ Psychotherapy ≥ 53 minutes/ $200.00
(This fee is my hourly rate &
used for all prorated calculations as
indicated)

90837/ Psychotherapy > 53 minutes/ $225.00
(This fee is for in-home & in-community
session locations)

90846/ Family Psychotherapy without Patient/ $250.00

90847/ Family Psychotherapy with Patient/ $250.00

90853/ Group Psychotherapy/ $200.00

98966-98968/ Telephone Assessment & Management/ Prorated based on the
amount of time spent at hourly rate

98970-98972/ Online Digital Evaluation & Mgt-(Responding to Email & Text Messages) / Prorated based on the amount of time spent at hourly rate

Cancelation Fee/ Your Therapist Requires a 24-Hour Cancelation Fee/ You are Responsible for the Fee of the Appointment Missed

Production of Records/ This fee is my hourly rate & used for all prorated calculations as indicated/ $200.00

Legal Fees/ This fee is my Clinical Supervisor's hourly rate & used for all prorated calculations as indicated/ $200.00

Total Estimate: This Good Faith Estimate explains your therapist’s rate for each service provided. Your therapist will collaborate with you throughout your treatment to determine how many sessions and/or services you may need to receive the greatest benefit based on your diagnosis(es)/presenting clinical concerns.

**Please note that Place of Service (in office vs. telemental health) is not delineated above since the charges are identical.**