Good Faith Estimate

Creating Changes Counseling
Kristin White, MA, LPC
281-937-4737
Krissy.White@CreatingChangesCounseling.com

Client Information

* Client

First name:

Last name:

Date of birth:

* Client Contact Information

Street or PO box:

City, state, ZIP:

Phone number:

Email address:

In accordance with the No Surprises Act, you have a right to know the estimated cost of you healthcare treatment.

Your mental health is a financial investment. Think of it like a gym membership, but for your mind so you can live a happy, healthy, fulfilled life.

You will receive 50-minute individual therapy sessions weekly as scheduled until otherwise indicated. The service code for this service (45-minute psychotherapy) is 90834. Any additional items or services that are recommended must be scheduled or requested separately and may have additional fees.
It is not possible to receive a mental health diagnosis before beginning counseling. However, all individual mental health diagnoses will have the same rate per session and use the same service code for individual psychotherapy.

Your psychotherapy sessions will be provided to you by your therapist:
Kristin White, MA, LPC
Your provider’s NPI Number is 1366845562
Creating Changes Counseling’s TIN/EIN is 83-2962215

The business address of Creating Changes Counseling is:
633 E. Fernhurst Dr.

Suite 501

Katy, TX 77450

Your therapy will take place online through teletherapy and you will be located in your own home or other private location in the state of your therapist’s licensing (Illinois or Texas).

The fee for therapy is $185.00 per 50-minute session for individual psychotherapy. While many patients attend therapy for several months, it is not possible to know in advance how many sessions a person may need. If you attend therapy weekly, your estimated fees for one month (4 visits) will be $740.00.

This good faith estimate is only an estimate, and it is possible that actual charges may differ. The patient has the right to initiate the patient-provider dispute resolution process if the actual bill substantially exceeds the expected charges in the good faith estimate. The good faith estimate is not a contract and does not obligate the patient to obtain the items or services from the provider identified in the good faith estimate. You may contact this health care provider or facility 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 or call HHS at (800) 368-1019. 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) 368-1019.

Insurance Opt Out Agreement

Creating Changes Counseling does not accept insurance as a method of payment. By using these services, you understand you are waiving the usage of your insurance. You are,however, more than welcome to use your HSA/FSA accounts for payment. You are
responsible for understanding your insurance benefits to include the co-pays and
deductible coverages available to you by choosing to work with a mental health
provider within your insurance company’s network. Those amounts may or may not
be less than the fees you agree to pay Creating Changes Counseling. Your signature on this GFE indicates your waiver of insurance benefits and your agreeance to paying out of-pocket fees as listed above.
At any time, you may request Out of Network Billing statements, called a Superbill,
from Creating Changes Counseling. This statement will include Dates of Service, Billing
Codes, and Diagnostic Codes. You may choose to submit these statements to your
insurance company to request reimbursement. Your signature on this GFE
indicates that the reimbursement decision is solely that of your insurance provider
and Creating Changes Counseling in no way guarantees or has authority in this reimbursement decision.

* I understand and agree that (Please check ALL the boxes):

I have voluntarily elected not to use my insurance for counseling sessions

Opting out of my insurance means that I must pay out-of-pocket for the counseling sessions

If I choose later to use my insurance, my therapist is not liable and is not obligated to reimburse previous sessions where I have chosen to opt out of billing my insurance;

My opting back into using insurance will start from the day I notify my therapist of the change and cannot be backdated to previous sessions

* By checking this box you are eSigning this document.

By checking this, you are eSigning this form.