Good Faith Estimate (Blank Form)
Orange County Psychological Services
Don Campbell Psy.D.
657-333-2725 – DonCampbellPsyD@gmail.com
19712 MacArthur Blvd. Ste 110, Irvine C.A, 92612
The date of the Good Faith Estimate is ___/____/___. This estimate is for psychotherapy services is good for 12 months.
A brief explanation of estimate for new patients:
The estimate below is the cost likely for most new patients. Until I do an initial evaluation and we start working together, I will not have a clear picture of your specific diagnosis, issues, and needs. I typically see therapy patients for an initial 12 sessions at a total cost of $225 per session. However, in many cases, a patient’s issues may be more complicated, so we may need additional sessions during the time covered by this estimate.
A brief explanation for continuing patients: The estimate below is the cost likely for your care covered by this estimate over the specified period covered. However, more or fewer sessions may be needed depending on how treatment progresses.
Contact: If you have questions about this estimate, please get in touch with Dr. Campbell at 657-333-2725 or doncampbellpsyd@gmail.com
Details of the Estimate
The following is a detailed list of expected charges for psychological services scheduled for 12 appointments over three months. The estimated costs are valid for 12 months from the date of this Good Faith Estimate unless I send you an updated Estimate.
Service:
Diagnosis code (use ICD codes):
Service code:
Quantity (# of sessions or units. Give a number or range):
Cost per session or unit: $225/session
Expected cost: 2700.00 for 12 sessions
Total estimated cost: $____$225/session____________
Psychologist providing services: Name _Don Campbell Psy.D______________ [you can delete this if you are a solo practitioner or the practice name is the same as the treating psychologist]
NPI number: 1730830316 TIN: 88-0629152
Patient information:
Patient name _______________________________________ DOB ______________
Disclaimer
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 estimate is based on the information known to me when I did the 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, federal law allows you to dispute (appeal) the bill.
You have the right to dispute the bill if you are billed for $400 more than this Good Faith Estimate (GFE).
You may contact the psychologist/ at the contact listed above to let them know the billed charges are at least $400 higher than the GFE. You can 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 (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 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.
Please keep a copy of this Good Faith Estimate (GFE) in a safe place or take pictures of it. You may need it if you are billed more than $400 than the estimate provided above.