Good Faith Estimate for Health Care Items and Services

Client Diagnosis

Without meeting you, I am unable to provide you with a diagnosis as part of this Good Faith Estimate. Any diagnosis code(s) I assign you following your initial assessment may or may not meet the standard of medical necessity established by your insurer. You should be aware of this, particularly if you plan to seek insurance reimbursement on your own.

Services Requested (Type and CPT Codes)

90791 - Psychiatric Diagnostic Evaluation
90837 - Psychotherapy, 60 minutes (53+ minutes)

Provider and Practice Information

Provider name: Stephanie Helena Best
Provider license number: North Carolina #4045 / South Carolina #1637
Practice name: Dr. Stephanie Best LLC
Practice address: Charleston, SC 29412 (online/virtual)
Phone: 843-580-2001
Email: stephanie@drstephaniebest.com
National Provider Identifier (NPI): 1174826242
Taxpayer Identification Number (TIN): 93-1466870

Introduction and Purpose of This Document

You are entitled to receive this “Good Faith Estimate” of what the charges could be for psychotherapy services provided to you. While it is not possible for a psychotherapist to know, in advance, how many psychotherapy sessions may be necessary or appropriate for a given person, this form provides an estimate of the cost of services provided. Your total cost of services will depend upon the number of psychotherapy sessions you attend, your individual circumstances, and the type and amount of services that are provided to you.

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

Estimated Charges

The fee for the initial 120-minute Comprehensive Psychodiagnostic and Mental Wellbeing Assessment is $590. The fee for each subsequent 60-minute individual psychotherapy session is $295. Most clients will attend one psychotherapy session per week for at least the first few months of treatment, but the frequency of psychotherapy sessions that are appropriate in your case may be more or less than once per week, depending upon your needs. Based on attending one session per week for one year, the following are expected charges of psychotherapy services. The estimated costs are valid for approximately 12 months from the date of the Good Faith Estimate; however, fees are reviewed annually and may change at any time. You will be given at least 60 days’ notice of any fee changes.

1 week of service = $295
1 week of service + initial 120-minute assessment = $885
13 weeks of service (approx. 3 Months) = $3,835
13 weeks of service + initial 120-minute assessment = $4,425
26 weeks of service (approx. 6 months) = $7,670
26 weeks of service + initial 120-minute assessment = $8,260
39 weeks of service (approx. 9 months) = $11,505
39 weeks of service + initial 120-minute assessment = $12,095
52 weeks of service (approx. 12 Months) = $15,340
52 weeks of service + initial 120-minute assessment = $15,930

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. 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 added 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. 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.

Dispute Process

If you are billed for more than this Good Faith Estimate, you have the right to dispute the bill. 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. 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. You are encouraged to speak with your provider at any time about any questions you may have regarding your treatment plan, or the information provided to you in this Good Faith Estimate.