The No Surprises Act was passed in December 2020, under Section 2799B-6 of the Public Health Service Act, with the aim of protecting consumers from receiving unexpected medical bills. The Good Faith Estimate provision of the No Surprises Act federally mandates that healthcare providers must give clients an estimate of anticipated healthcare items and services, using what is called a “Good Faith Estimate.” This took effect on January 1, 2022. This page includes important information about the Good Faith Estimate. A written version of this document with specific charges for services will be provided to you should you decide to engage in therapy with me.

Below is the mental health provider who will be giving you services and this Good Faith Estimate reflects their charges. 

Jessica Gottlieb of Jessica Gottlieb LCPC, LLC - NPI: 1073867214

Therapy is taking place via telehealth and in person.

Your therapist is not able to provide a Client Diagnosis before doing an assessment. However, typically, the initial diagnosis is F43.20, Adjustment Disorder, unspecified, which is what will be used for the services and fees of this Good Faith Estimate. As well, this diagnosis may change during the course of treatment.

Charges are for an Initial Intake Assessment and the types of weekly sessions you will have, typically, but this might change depending on the needs of treatment. Given that the course of treatment depends on your needs, there is no way to estimate how many sessions you will want or need to feel better. Therefore, you and the mental health provider will be working together to determine the number of sessions. Total Expected Charges will vary depending on the number of sessions you have which you and your therapist will decide together. 

Most clients are scheduled for individual therapy using code 90834 for weekly, 50 minute sessions.

Clients are allowed to have three times a year that they cancel an appointment regardless of how much notice is given before a session with no charge. After a client exceeds three times of missed sessions in a calendar year, they may be billed for all sessions missed in full. Clients who miss their scheduled session without giving any kind of advance notice are charged in full for their missed session.

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.

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.

This estimate does not require you to obtain psychotherapy or other services from the 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 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.

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.

Should you engage with therapy with Jessica Gottlieb LCPC LLC, you will be provided with a more detailed version of this estimate for you to sign and return. If you are not able to return it signed, please send an email that states “I am sending this email to acknowledge I have received the Good Faith Estimate from Jessica Gottlieb LCPC LLC and this email serves as my electronic signature of it.”