Good Faith Estimate and No Surprise Billing

In accordance with the No Surprises Act, effective January 1, 2022, Integrative Behavioral Health & Healing Practice wants to ensure that all patients are aware they can receive a “Good Faith Estimate” to help them estimate the expected charges they may be billed for receiving healthcare services performed by Integrative Behavioral. This applies to any patients who are out-of-network, uninsured or who is insured but does not plan to use their insurance benefits to pay for health care services.

Please see the Good Faith Estimate and Your rights and protections against surprise medical bills information below.

Good Faith Estimate and Your Rights and Protections Under the No Surprises Act

You have the right to receive a Good Faith Estimate for the total expected cost of any health care items or services upon request or when scheduling such items or services. This includes related costs with medication management, psychotherapy, and testing services. The Good Faith Estimate is not a bill. The cost for needed services included in the Good Faith Estimate does not include any unknown or unexpected costs that may arise during treatment.

You could be charged more if special circumstances occur. The Good Faith Estimate is not a contract and does not require the uninsured (or self-pay) patient to obtain the services from any of the providers identified.

This Good Faith Estimate is not intended to serve as a recommendation of treatment or a prediction that you may need to attend a specified number of medication management or psychotherapy visits. The number of visits that are appropriate in your case, and the estimated cost of those services, depends on your needs and what you agree to in consultation with your provider. You are entitled to disagree with any recommendations made to you concerning your treatment and you may discontinue treatment at any time.

Initially, patients may be seen every one to four weeks, with visits extending from every month to six months, once stable. Your total cost of services will be dependent upon the mental health services that are offered to you, frequency of services, total number of services, as well as individual circumstances.

How long you need to engage in mental health services and how often you attend sessions will be influenced by many factors including your schedule and life circumstances, the progress in therapy or treatment, ongoing or new life challenges, and personal finances.

You and your provider will continually assess the appropriate frequency of sessions and will work together to determine when you have met your goals and are ready for discharge and/or a new Good Faith Estimate will be issued should the frequency of session(s) or needs change. As related, you may request a new Good Faith Estimate at any time in writing during your treatment.

A Good Faith Estimate:

  • Does NOT include no-shows, late cancellations, or other services related to crisis care, which by definition are unexpected and cannot be predicted for the purpose of compiling a Good Faith Estimate in advance.
  • May also include fees related to paperwork requests and other legal and administrative fees related to patient care, when such items are scheduled in advance.

The following list contains appropriate types of services and the associated charges:

New Patient Evaluation (60 min): $300

Returning Patient Appointment- Not Seen Within the Last Year (40-60 min): $300

Follow Up Appointment (20-30 min): $150

Follow-up Appointment with Therapy (40-60 min): $200

Psychological Testing: $400

If you think you have been wrongly billed, you may contact the following:

The Billing Manager, Renee Shadley via email at [email protected] or by phone at 1-877-454-9036 from 8 a.m. to 4:30 p.m. EST, Monday through Friday.

The Operations Manager, Lauren Swilley via email at [email protected] or by phone at (984) 288-0880 from 8 a.m. to 4:30 p.m. EST, Monday through Friday.

For questions or more information about your right to a Good Faith Estimate or the dispute process, visit or call (800) 985-3059.

PRIVACY ACT STATEMENT: CMS is authorized to collect the information on this form and any supporting documentation under section 2799B-7 of the Public Health Service Act, as added by section 112 of the No Surprises Act, title I of Division BB of the Consolidated Appropriations Act, 2021 (Pub. L. 116-260). We need the information on the form to process your request to initiate a payment dispute, verify the eligibility of your dispute for the PPDR process, and to determine whether any conflict of interest exists with the independent dispute resolution entity selected to decide your dispute. The information may also be used to: (1) support a decision on your dispute; (2) support the ongoing operation and oversight of the PPDR program; (3) evaluate selected IDR entity’s compliance with program rules. Providing the requested information is voluntary. But failing to provide it may delay or prevent processing of your dispute, or it could cause your dispute to be decided in favor of the provider or facility.

Good Faith Estimate and No Surprise Billing