Good Faith Estimate

GOOD FAITH ESTIMATE FOR HEALTH CARE ITEMS AND SERVICES

JANA HARTJEN, PSY.D, LLC/

Emotionally Nourished Therapy

Dear Patient,

The No Surprises Act was passed in December 2020, under Section 2799B-6 of the Public Health Service Act, with the aim of protecting consumers from receiving unexpected medical bills. This took effect on January 1, 2022.

The Good Faith Estimate provision of the No Surprises Act is an estimate of total expected costs of non-emergency healthcare items or services.  The estimate does NOT apply to late cancellations, no-show fees, or crisis care services—as these are not expected services that can be calculated.  This act applies to when services are rendered by an out-of-network provider, if a client is uninsured, or if a client elects not to use their insurance. 

Below is the content of the Good Faith Estimate form you would receive if you are paying for your own sessions/not using insurance. We may/will intermittently update it when service expectation frequency markedly changes or when other conditions arise indicating the need for an updated GFE. I also update all active client’s GFEs at a set 4-month increment (currently January, May, September)—independent of when client begins treatment-- as an added measure of treatment check-ins. 

We will continually assess the appropriate frequency of therapy and will work together to determine when you have met your goals and are ready for discharge.

Thank you very much,

Jana Hartjen, Psy.D, Licensed Psychologist

NJ: 35SI00681800

PA: PS018945

NPI2: 1366296865

GOOD FAITH ESTIMATE FOR HEALTH CARE ITEMS AND SERVICES

JANA HARTJEN AT EMOTIONALLY NOURSHED THERAPY

After Reviewing, please be sure to sign page 5 and 6 of this document

DATE OF CREATION OF GOOD FAITH: 

DATE OF EXPIRATION OF GOOD FAITH: 

(this form may be renewed every 4 months or as needed)

PATIENT IDENTIFIYING INFORMATION:

PATIENT’S FULL NAME: 

PATIENT DATE OF BIRTH:

PATIENT MAILING ADDRESS:

PATIENT PHONE NUMBER:

PATIENT EMAIL ADDRESS:

PATIENT’S CONTACT PREFERENCE:  (EMAIL OR PHONE)

PRIMARY SERVICE OR ITEM REQUESTED/SCHEDULED:

PATIENT PRIMARY DIAGNOSIS AND DIAGNOSIS CODE:

PATIENT SECONDARY DIAGNOSIS AND DIAGNOSIS CODE:

IIF SCHEDULED, LIST THE DATE(S) THE PRIMARY SERVICE OR ITEM WILL BE PROVIDED:

90791--Psychiatric Intake Assessment (if virtual; 90791—95, 90791—10)

90834—45 minutes of Individual Psychotherapy (if virtual:  90834—95;  90834—10)

90837—53 minutes of Individual Psychotherapy (if virtual:  90837—95; or 90837—10)

Both services codes and diagnosis codes can change throughout the arc of your individualized therapy; however, those changes generally do not affect individual pricing.

Details of Service and Total Expected Charge

(Information is applicable until either: 1. Expiration Date listed on first page, 2. Patient/Therapist need to renew estimate due to treatment plan change, 3. Therapeutic relationship ends prior to expiration date)

ESTIMATES DO NOT INCLUDE LATE CANCELLATIONS OR NO-SHOW FEES

ESTIMATED TOTAL CHARGES:  _________________________

(during CURRENT Good FAITH ESTIMATE only)

PATIENT SIGNATURE ________________________________  DATE  _________________

PROVIDER SIGNATURE _____________________________ DATE ___________________

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, and does not include any unknown or unexpected costs that may arise during treatment.

IF YOU ARE BILLED FOR MORE THAN THIS GOOD FAITH ESTIMATE, YOU HAVE THE RIGHT TO DISPUTE THE BILL.

Throughout your treatment, the provider may recommend additional items or services as part of your treatment that are not reflected in this estimate. These would need to be scheduled separately with your consent and the understanding that any additional service costs are in addition to the Good Faith Estimate.

If your needs change during treatment, your provider should supply a new, updated Good Faith Estimate to reflect the changes to treatment, and the accompanying cost changes. 
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.
The Good Faith Estimate is not a contract between provider and client and does not obligate or require the client to obtain any of the listed services from the provider. 

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) 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 (800) 985-3059. 
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.

Contact: If you have questions about this estimate, please contact the Practice Owner –Jana Hartjen, PsyD.  856-208-7225. 

The Good Faith Estimate is not a contract between provider and patient and does not obligate or require the client to obtain any of the listed services from the provider. 
Your provider's signature is provided below.