Good Faith Estimate

Right to Receive a Good Faith Estimate of Expected Charges - Under the "No Surprises Act"

Listed below are the services offered at Bourne Therapeutic Services, along with estimated rates, except when otherwise agreed upon with Krystal Roames:

- 15 minute Consultation for new patients: free
- Intake Appointments (45 min): $125 [service code 90791]
- Individual Therapy (45 min): $125 [service code 90834]

-Administrative Fees (for completing any letters or forms): $75/hr (1 hour minimum)

Diagnosis codes are unique to each patient and not listed above. The fees above are listed in your consent forms, which you will have signed when we first begin treatment together (some rate changes may apply). At this time, there is no change to your current fees for working with me.

There is no predetermined timeline for how long you will be in therapy. Krystal Roames provides long-term, strengths-based, and trauma-focused treatments, along with integrative treatments that are individualized to best serve the needs of each patient (these include cognitive behavioral therapy, mindfulness training, emotion-focused therapy, motivational interviewing, and person-centered therapy, among other modalities). The late cancellation (less than 24-hours notice) or no show fee is equivalent to a full session fee.

You have the right to receive a "Good Faith Estimate" explaining how much your medical care will cost.

Disclaimer

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, and does not include any unknown or unexpected costs that may arise during treatment.

If you are billed for more than this Good Faith Estimate, you have the right to dispute the bill.
Throughout your treatment, the provider may recommend additional items or services as part of your treatment that are not reflected in this estimate. These would need to be scheduled separately with your consent and the understanding that any additional service costs are in addition to the Good Faith Estimate.

If your needs change during treatment, your provider should supply a new, updated Good Faith Estimate to reflect the changes to treatment, and the accompanying cost changes.

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.

The Good Faith Estimate is not a contract between provider and client and does not obligate or require the client to obtain any of the listed services from the provider.

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) 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.