Health care providers are required to give new, prospective, or established patients who are uninsured, or self-pay, a good faith estimate of costs for services that they provide. While it is not possible for a provider to know, in advance, how many sessions may be necessary or appropriate for a given person, this website page provides an estimate of the cost of services rendered that are provided per session or appointment. Your total cost of services will depend upon the number of clinical appointments you attend, your individual circumstances, and the type and/or amount of services that are provided to you. Your provider will collaborate with you throughout your treatment to determine how many sessions and/or services you may need to receive the greatest benefit based on your diagnosis(es)/presenting clinical concerns. This estimate is not a contract and does not obligate you to obtain any services from Cognia Health, nor does it include any services rendered to you that are not identified here.

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 appointments. Many patients will attend one visit every four to twelve weeks, but the frequency of visits that are appropriate in your case may be more or less, depending upon your needs. The number of appointments 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 provider. You are entitled to disagree with any recommendations made to you concerning your treatment and you may discontinue treatment at any time.

The amount below is only an estimate, and it is not an offer or contract for services. This estimate shows the full estimated costs of the items or services listed. This means that the final cost of services may be different than this estimate.

Good Faith Estimates:

• Initial Psychiatric Evaluation – 60 minutes (CPT 90792, 99203, 99204, 99205): $300

• Initial Psychiatric Evaluation – 90 minutes (CPT 99205+99417): $450

• Follow-up Appointment – 20-30 minutes (CPT 99213, 99214): $150

• Follow-up Appointment – 31-60 minutes (CPT 99214, 99214 + 90833, 99215, 99215 + 90833, 99215+99417): $300

• Prescriptions outside of an appointment: $30

• Communications that require tasks longer than 5 minutes and up to 15 minutes: $50-$75

• Communications that require tasks longer than 5 minutes and up to 30 minutes: $150

• Paperwork or any other form of documentation not completed during the appointment: $50 per page

• Missed appointments or cancellations less than 48 hours in advance will be charged in full

The Good Faith 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. In those cases, we recommend that you contact your clinician 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. Most importantly, starting a dispute will not adversely affect the quality of health care services at Cognia Health.

With your electronic signature in the Policies and Procedures form, you are agreeing to receive services at Cognia Health and consenting of your own free will and are not being coerced or pressured. You understand that you may be giving up some consumer billing protections under federal law, and that you will get a bill for the full charges for these items and services and pay out-of-network cost-sharing under your health plan. Also, you recognize you were given a written notice explaining that Cognia Health isn’t in your health plan’s network, the estimated cost of services, and what you may owe. Furthermore, you fully and completely understand that some or all amounts you pay might not count toward your health plan’s deductible or out-of-pocket limit. You can end this agreement by notifying Cognia Health in writing before getting services.

You don’t have to sign this agreement in the Policies and Procedures form. But if you don’t sign, Cognia Health will not be able to provide psychiatric services. To the extent you are insured, you can choose to get care from a provider or facility in your health plan’s network.