Dr. Tracy Bennett Psychological Services, Inc.

Tracy Bennett, PhD
Licensed Clinical Psychologist, PSY15696
340 Rosewood Avenue, Suite A
Camarillo, CA 93010
DrTracy@DrTracyBennett.com
805-383-0882

NPI: 1285790360    TAXID: 83-3414238

Pursuant to the No Surprises Act (HR133, Title 45 Section 149.610), this form is used to provide a current or prospective client with a “Good Faith Estimate” (GFE) of expected charges for services to be provided.  This template is a hybrid of ones recommended by several therapist professional associations.

You are entitled to receive this “Good Faith Estimate” of what the charges could be for psychotherapy services provided to you. While it is not possible for a psychotherapist to know, in advance, how many psychotherapy sessions may be necessary or appropriate for a given person, this form provides an estimate of the cost of services provided. Your total cost of services will depend upon the number of psychotherapy 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 the provider(s) listed, nor does it include any services that may be recommended during treatment to you that are not identified here. 
 
This Good Faith Estimate is not intended to serve as a recommendation for treatment or a prediction that you may need to attend a specified number of psychotherapy visits. The number of visits that are appropriate in your case and the estimated cost for those services depends on your needs and what you agree to in consultation with your therapist. You are entitled to disagree with any recommendations made to you concerning your treatment and you may discontinue treatment at any time. 
 
 
The fee for a 45-minute psychotherapy visit (in person or via telehealth) is $180.  Most clients will attend one psychotherapy visit per week, but the frequency of psychotherapy visits that are appropriate in your case may be more or less than once per week, depending upon your needs.  Based on this per visit fee cited above, the following are expected charges of psychotherapy services:

                                  Total Estimated Charges   Total Estimated Charges
Number of Weeks      for 1 Session per Week     for 1 Session per 2 Weeks

1 Week of Service                       $180                                   $180

13 Weeks of Service                    $2340                                 $1170
  (approx 3 mos)

26 Weeks of Service                    $4680                                 $2340
  (approx 6 mos)

39 Weeks of Service                    $7020                                 $3510
  (approx 9 mos)

52 Weeks of Service                    $9360                                 $4680
  (approx 12 mos)

You have a right to dispute a bill if the actual amount charged to you substantially exceeds the estimated charges stated in your Good Faith Estimate (which means $400 or more beyond the estimated charges). Initiating the dispute process will not adversely affect the quality of services rendered to you. 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, 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. 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.
 
You are encouraged to speak with your provider at any time about any questions you may have regarding your treatment plan, or the information provided to you in this Good Faith Estimate.