You are entitled to receive this Good Faith Estimate of what the charges may be for Clinical Social Work Services/Psychotherapy services provided to you. While is is not possible for a practitioner to know, in advance, how many sessions may be necessary or appropriate for a given person, this form provides an estimate of the cost of services provided. Your total cost will depend upon the number of sessions you attend, your individual circumstances, and the type and amount of services that are provided to you.
This estimate is not a contract and does not obligate you to obtain any services from Anne G. Walker LCSW nor does it include any services rendered to you that are not identified here.
The estimate is based upon 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. There may be addtional services I may recommend as part of your care that must be scheduled separately and are not reflected in this estimate. You could be charged more if complications or special circumstances occur. If this happens, federal law allows you to dispute or appeal the bill.
You have the right to initiate a dispute resolution process if the actual amount charged to you substantially exceeds the estimated charges stated in the estimate (which means $400 or more beyond the estimate).You may contact Anne G. Walker LCSW to alert that the charges exceed the estimate, ask her to update the bill to match the 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 the dispute resolution process you must initiate it within 120 calendar days of the date of the original bill. There is a $25 fee for the dispute resolution process. If the agency reviewing the dispute agrees with you, you will have to pay the amount on the Good Faith Estimate. If the agency agrees with the provider, you will have to pay the higher amount.
For questions visit https://www.cms.gov/nosurprises/consumers or call (800) 985-3059.The initiation of the patient-provider dispute resolution process will not adversely affect the quality of services furnished to you.