Good Faith Estimate

OMB Control Number: 0210-0169

In compliance with the No Surprises Act that went into effect January 1, 2022, all healthcare providers are required to notify clients of their Federal rights and protections against “surprise billing.”

This Act requires that I notify you of your federally protected rights to receive a Good Faith Estimate of services and associated fees as an out-of-network provider, and when clients are uninsured or elect not to use their insurance.

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 or counseling services.

Please review, complete and sign in acknowledgement of receipt of this document prior to your next appointment. If you have any questions, please don’t hesitate to ask.

Primary Services to be Provided

Services include psychotherapy in the context of Individual, Couples or Family Therapy and will be provided at a frequency determined by the client and therapist as treatment goals are identified and established. Therapy services are provided by Athen Fisher, LMFT or Penelope Hatter, LMFT. At this time, there are no items or services expected in addition to these services through Love Story Therapy, PLLC (LST).

Diagnosis Codes:

Psychotherapists do not diagnose individuals before meeting them and assessing their needs and overall functioning. Some individuals may not meet criteria for a mental health diagnosis and instead a Z code may be assigned, which represents the general areas of concern to be addressed in therapy. Please speak with your therapist if you have any questions or concerns about the diagnostic process or a specific diagnosis. Please note- as I am an out-of-network provider, your diagnosis will only be shared with an outside entity if you choose to submit a superbill to your insurance company after services are provided.

Common Diagnosis Codes:

• Adjustment Disorder (F43.23)
  
  
• Depression (F32.0-F33.3)
  
  
• Generalized Anxiety Disorder (F41.1)
  
  
• PTSD (F43.10)
  
  
• Parent-child relational problems (Z62.820)
  
  
• Problems in relationship with spouse or partner (Z63.0)
  
  
• Problems of adjustment to life cycle transitions (Z60.0)

Common Service Codes Used and Service Fees:

• 50-55 min. Diagnostic Evaluation (90791)- $165 (Athen Fisher) and $155 (Penelope Hatter)
  
  
• 50-55 min. Individual Therapy Session (90834/90837)- $165 (Athen Fisher) and $155 (Penelope Hatter)
  
  
• 50-55 min. Family/Couples Conjoint Therapy Session (90847)- $165 (Athen Fisher) and $155 (Penelope Hatter)

Other Possible Fees:

• Late Cancellation (canceling with less than 24 hours notice)/No Show Fee: $165 (Athen Fisher) and $155 (Penelope Hatter)
  
  
• Phone Call or Consultation over 15 minutes: $165 (Athen Fisher) and $155 (Penelope Hatter)
  
  
• Additional Requested Written or Consultation services (outside of session, billed in 15 minute increments): $165 (Athen Fisher) and $155 (Penelope Hatter)

Total Expected Costs in a 12 Month Period

Depending on treatment goals, presenting needs and areas of focus, personal finances, therapist availability, client schedule and availability, etc., you may attend between 12 and 52 50-55 minute sessions within a year. At $165 per session, the estimated total costs are between $1,980 and $8,580 over the next year. At $155 per session, the estimated total costs are between $1,860 and $8,060 over the next year.  It is important to note that this an estimate only and actual costs may be outside of the above range.

*Please note- Service rates may increase in the future and current estimates are based upon current rates. The No Surprises Act requires that you be notified of any rate changes within one business day of scheduling a service to be provided in 3 business days, or within 3 business days of schedule a service to be provided in at least 10 business days.

Provider Information

Providers names: Athen Fisher, MAS, LMFT (LMFT-15157) and Penelope Hatter, MA, LMFT

Provider/facility: Love Story Therapy, PLLC.

Facility address: 1600 W. Chandler Blvd., Ste 220, Chandler AZ 85224

Contact person: Athen Fisher

Phone: 480-620-6799 Email: athen@lovestorytherapy.com

National Provider Identifier (NPI): 1841734886

Taxpayer Identification Number (TIN): 84-4444555

Disclaimers

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 At this time, no items or services are anticipated to require separate scheduling either prior to or following the expected period of care for the primary item or service that will be charged by this facility or provider.

If your needs change during treatment, you will be provided with an 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.

If you are billed for more than $400 more 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 and work toward a resolution. 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 must the price on this Good Faith Estimate. If the agency disagrees with you and agrees with the health care provider or facility, you must 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.

Please print or keep this Good Faith Estimate in a safe place as you may need it if you wish to dispute any charges.