Good Faith Estimate

About This Good Faith Estimate

Under the No Surprises Act, you have the right to receive a "Good Faith Estimate" (GFE) of the expected charges for mental health services. This document provides that estimate and explains your rights regarding billing and payment.

I am a private pay provider, which means you pay me directly for services. I am not a credentialed provider with insurance companies. However, I provide superbills that you can submit to your insurance for out-of-network reimbursement consideration.

Service Costs

Service	Duration	Cost per Session
Initial Consultation	15 minutes	No charge (complimentary)
Individual Therapy Session	50 minutes	$200
Couples Therapy Session	60 minutes	$300
Intensives	6 or 12 sessions plus support	Costs vary

Intensive pricing: costs vary based on program length and format.

Example Cost Estimates

Here are examples of estimated costs for common therapy scenarios. Actual costs may vary based on frequency of sessions and duration of treatment.

What This Estimate Includes

• Clinical therapy sessions only
• Does not include missed appointment fees (charged if cancelled with less than 48 hours' notice)
• Does not include superbill fees (there are none; superbills are provided at no additional cost)
• Does not include cost of telehealth platform fees (included in session cost)
• Does not include non-billable time (emails, phone calls between sessions)

Payment & Billing

When: Payment is due at the end of each session.

How: I accept cash, check, and digital payment methods.

Superbills: After each session, I provide an itemized invoice (superbill) that you can submit to your insurance company for out-of-network reimbursement. There is no additional charge for superbills. Your insurance will reimburse you directly based on your plan's out-of-network benefits.

Actual Out-of-Pocket Cost: Your actual cost will depend on your insurance plan's out-of-network reimbursement rate. Contact your insurance company to ask about:

• Out-of-network mental health benefits
• Your deductible status and annual maximum
• Percentage of coverage for outpatient therapy
• Any limits on the number of sessions per year

Your Rights Under the No Surprises Act

You have the right to:

• Receive a Good Faith Estimate before services are provided
• Ask questions about the estimate if you don't understand it
• Understand that this is an estimate, not a bill
• Understand that actual charges may vary based on the services you receive
• Dispute charges that exceed this estimate by 10% or more

Disputing Charges

If you believe you have been billed in excess of what was estimated (more than 10% above this estimate), you have the right to dispute the charges. To file a dispute:

1. Contact me directly at hello@drjenniferwilson.com
2. Provide details of the disputed charges and the reason for your dispute
3. I will respond within 30 days to discuss the charges
4. If we cannot resolve it, you may file a complaint with the Centers for Medicare & Medicaid Services (CMS) at cms.gov/nosurprises

Important Notes

• This estimate is based on information known at the time of request. If treatment needs change, costs may change accordingly.
• This estimate is valid for 60 days from the date of this document.
• If you do not begin services within 60 days, please request a new estimate.
• No cancellation fees will be charged if you decide not to proceed with therapy after receiving this estimate.

Questions About This Estimate?

I'm happy to discuss this estimate, answer questions about costs, or help you understand your insurance coverage. Feel free to reach out anytime.