Under Section 2799B-6 of the Public Health Service Act, health care providers and health care facilities are required to provide a good faith estimate of expected charges for items and services to individuals who are not enrolled in a plan or coverage or a Federal health care program, or not seeking to file a claim with their plan or coverage both orally and in writing, upon request or at the time of scheduling health care items and services.
This is NOT a bill.
Wise Mind Counseling
321 St. George Street, Green Bay, WI 54302
217 N. 4th Avenue Sturgeon Bay, WI 54235
Kim Marohl, LPC
NPI: 1760629026 | Tax ID: 87-2305969
Diagnosis Information:
I am not able to propose an appropriate diagnosis or course of treatment for you until we have spent sometime together. As soon as I am able to identify a diagnosis and an appropriate course of treatment, I will discuss it with you.
Details of Services and Items for Wise Mind Counseling:
Per session rate (in-person and tele-health services):
$255 for intake session
$205 for 55 minute individual or family session x 52 = $10,660 annual
$155 for 45 minute individual or family session x 52 = $8,060 annual
$105 for 30 minute individual or family session x 52 = $5,460 annual
The intake session is anticipated to be one initial meeting. Follow- up services are anticipated to be provided generally on a weekly basis until treatment is terminated. Follow-up services can be offered at varying durations of session time and costs.
Additional services may be recommended. This estimate of your costs is only an estimate, and your actual charges may differ.
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.
The Good Faith Estimate is not a contract and does not require the uninsured (or self-pay) individual to obtain the items or services from any of the providers or facilities identified in the Good Faith Estimate.
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, and your bill is $400 or more for any provider or facility than your Good Faith Estimate for that provider or facility, federal law allows you to dispute the bill.
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.
If you dispute your bill, the provider or facility cannot move the bill for the disputed item or service into collection or threaten to do so, or if the bill has already moved into collection, the provider or facility has to cease collection efforts. The provider or facility must also suspend the accrual of any late fees on unpaid bill amounts until after the dispute resolution process has concluded. The provider or facility cannot take or threaten to take any retributive action against you for disputing your 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 http://www.cms.gov/nosurprises/consumers or call HHS at (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.**