No Surprises Act
The Federal government has enacted the No Surprises Act good faith estimate and this notice is in compliance with that act.
Services are Behavioral Medicine Associates are billed at a standard cost. Your insurance may pay less than our fees, as insurance establishes reasonable and customary fees. The costs outlined below are our standard fees.
Services are charged on a session-by-session basis. This estimate provides you with expected fees for each session that you may schedule or reschedule. Estimated costs are valid for 12 months from the completion date, unless otherwise informed of changes. The amount of total sessions you schedule will determine your overall total cost.
Contact: If you have questions about this estimate, please contact the office manager at 989-832-9161. Our office NPI number is 1740370089. Our office TIN is 38-3199675. Our office location is 1205 East Wackerly Street, Midland, MI 48642
Disclaimer-government required
This Good Faith Estimate shows the costs of services that are reasonably expected for the expected services to address your mental health care needs. 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. If this happens, federal law allows you to appeal the bill. If you are billed for $400 more (per provider) for any session in this Good Faith Estimate (GFE), you have the right to dispute the bill. You may contact the office to let them know the billed charges per session are at least $400 higher than the GFE. You may ask them to update the bill to match the GFE, 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, paid to HHS, to use the dispute process. If the agency reviewing your dispute agrees with you, you will have to pay the price on this GFE. 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 CMS at 1-800-985-3059.For questions or more information about your right to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprises or call CMS at 1-800-985-3059. This GFE is not a contract. It does not obligate you to accept the services listed above.
Keep a copy of this Good Faith Estimate (GFE) in a safe place or take pictures of it.
Patient name _______________________________________ DOB ______________
Date:________________________________
Services are Behavioral Medicine Associates are billed at a standard cost. Your insurance may pay less than our fees, as insurance establishes reasonable and customary fees. The costs outlined below are our standard fees.
| Service | Service Code | Fee |
| Initial Evaluation | 90791 | 235.00 |
| Psychotherapy (38-52 minutes) | 90834 | 180.00 |
| Psychotherapy (53 + minutes) | 90837 | 180.00 |
| Psychotherapy (16-38 minutes) | 90832 | 90.00 |
| Family | 90847 | 180.00 |
| Family without patient | 90849 | 180.00 |
| No shows, repeated cancellations | 25.00 up to 180.00 |
Services are charged on a session-by-session basis. This estimate provides you with expected fees for each session that you may schedule or reschedule. Estimated costs are valid for 12 months from the completion date, unless otherwise informed of changes. The amount of total sessions you schedule will determine your overall total cost.
Contact: If you have questions about this estimate, please contact the office manager at 989-832-9161. Our office NPI number is 1740370089. Our office TIN is 38-3199675. Our office location is 1205 East Wackerly Street, Midland, MI 48642
Disclaimer-government required
This Good Faith Estimate shows the costs of services that are reasonably expected for the expected services to address your mental health care needs. 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. If this happens, federal law allows you to appeal the bill. If you are billed for $400 more (per provider) for any session in this Good Faith Estimate (GFE), you have the right to dispute the bill. You may contact the office to let them know the billed charges per session are at least $400 higher than the GFE. You may ask them to update the bill to match the GFE, 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, paid to HHS, to use the dispute process. If the agency reviewing your dispute agrees with you, you will have to pay the price on this GFE. 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 CMS at 1-800-985-3059.For questions or more information about your right to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprises or call CMS at 1-800-985-3059. This GFE is not a contract. It does not obligate you to accept the services listed above.
Keep a copy of this Good Faith Estimate (GFE) in a safe place or take pictures of it.
Patient name _______________________________________ DOB ______________
Date:________________________________