Good Faith Estimate

Services Provided by Flourish Mental Health and Wellness:
• Psychotherapy
• Psychiatric Diagnostic Evaluation
Common Service and Service Codes used by Flourish Mental Health and Wellness:
• 90791 - First Appointment Evaluation
• 90837 - 53-minute Psychotherapy Session
• 90834 - 45-minute Psychotherapy Session
Brittany recognizes every client's therapy journey is unique. How long you need to engage in therapy and how often you attend sessions will be influenced by many factors including:
• Your schedule, availability, and life circumstances
• Therapist availability
• Ongoing life challenges (may increase or decrease frequency of sessions)
• The nature of your specific challenges and how you address them
• Personal finances
Together we will continually assess the appropriate frequency of therapy and will work to determine when you have met your goals and are ready for discharge.
Where services will be delivered:
• I am currently providing services via telehealth and in person at 420 E Main St Greenwood, IN until further notice; as such, all benefits will be quoted as virtual.
Client Diagnosis
As a therapist, I must diagnose clients for both ethical, legal, and insurance reasons -- as well as required by the "No Surprises Act."
Your Good Faith Estimate diagnosis is:
Z13.30 Encounter for screening for mental health diagnosis
This diagnosis is only to satisfy the federal requirement for this form and is not a formal psychological diagnosis.
It is within your rights to decline a diagnosis per state and federal guidelines.

Your Financial Responsibility Summary
For a good faith estimate: the amount you would owe if you were to attend therapy for 52 sessions in a year (weekly, without skipping any weeks for holidays, break, vacation, unplanned events/sickness, etc.). The "Good Faith Estimate" requires practitioners to provide an exact estimate and not a range. Out of an abundance of caution and transparency, I will only quote weekly appointments.
You and your therapist will continually address the appropriate frequency of therapy and will work together to determine when you have met your goals and are ready for discharge. Below you will see how much a year of therapy will cost if you were to meet with your therapist for 52 weeks in a year (weekly, without skipping any weeks) at the current full rate.
Brittany Dewbrew-Hale, LCSW's current full rate for counseling and psychotherapy services are: 50 minutes (Counseling/Psychotherapy): $120/session.
If you were to meet with Brittany Dewbrew-Hale, LCSW, weekly, at the price listed above, the cost for 52 sessions in a year would be: $100 X 52 = $6,240

Good Faith Estimate 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 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 dispute (appeal) the bill.
• The Good Faith Estimate does not include services not provided by your provider that you may need and that your provider may recommend. For instance, the Good Faith Estimate does not include the cost of seeking medication for mental health.
• The Good Faith Estimate is an estimate for services only and does not include other fees, such as fees for cancelling less than 24 hours in advance. These fees are outlined in the informed consent that is signed before the start of therapy services and that you have control over.
• This Good Faith Estimate is not a contract and does not obligate you to receive the services listed nor does it obligate you to receive the services listed by this provider.
• 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.
• 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 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 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.