MARY CLAIRE KERWIN, LCSW

Good Faith Estimate and Self-Pay Rates

“No Surprises Act”

Mental health providers are required to provide a good faith estimate at the time of scheduling an appointment of expected charges for services to clients who are not enrolled in a plan, coverage, or federal health care program. A document will be provided to inform uninsured or self-pay clients of the expected charges they may be billed for receiving certain services.

You are entitled to receive this "Good Faith Estimate" of what the charges for treatment services could be if you are self-pay or no longer eligible for your insurance benefits. As it is not possible for a provider to know, in advance, how many sessions may be necessary or appropriate for a given person, this is an estimate of the costs of services provided.

Your total cost of service will depend upon the number of sessions you attend, your individual needs, as well as the types and number of services that are provided to you. This estimate is not a contract and does not obligate you to obtain any services from Mary Claire Kerwin, LCSW.

The number of visits that are appropriate for you, and the estimated cost for those services, depend on your needs and what you agree to in consultation. You are entitled to disagree with any recommendations made to you concerning your treatment and you may discontinue treatment at any time.

Please see below for a summary of therapy session codes and the costs associated:

90791 Initial Assessment: $250
90837 Individual Session: $225
90847 Couple’s Session: $275

*Payment is due at the time of appointment or at a time agreed upon by therapist.

*The estimate is based on information known at the time the estimate was created. This 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. If you are billed for more than this estimate, you have the right to dispute the bill. You may contact the provider or facility listed on this form to let them know the billed charges are higher than the estimate. You can ask them to update the bill to match the 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 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 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. For questions or more information about your right to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprises. Keep a copy of this Good Faith Estimate in a safe place or take a picture of it. You may need it if you are billed a higher amount.